Answer Key
Question 1 See full question 10s
A preschool-age child with sickle cell anemia is admitted to the health care facility in
vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's
highest priority when caring for this child?
You Selected:
Administering antipyretics as ordered
Correct response:
Providing fluids
Explanation:
During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together
and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the
highest priority is providing I.V. and oral fluids, which promotes hemodilution and
aids the free flow of RBCs through blood vessels. The client must be kept away
from known infection sources but doesn't require protective isolation. Warm
compresses may be applied to painful joints to promote comfort; cool compresses
would cause vasoconstriction, which exacerbates sickling. Antipyretics may be
administered to reduce fever but don't play a crucial role in resolving the crisis.
Remediation:
Anemia, sickle cell, pediatric
Question 2 See full question 24s
A preschool-age child refuses to take ordered medication. Which nursing strategy is
most appropriate?
You Selected:
Showing trust in the child's ability to cooperate even with an unpleasant
procedure
Correct response:
, Showing trust in the child's ability to cooperate even with an unpleasant
procedure
Explanation:
To gain a preschooler's cooperation, the most appropriate strategy is for the nurse
to show trust and express faith in the child's ability to cooperate even with an
unpleasant procedure. Hiding the medication in milk may foster mistrust. The
nurse should provide simple, not detailed, explanations and should use terms the
child can understand. Shaming the child is inappropriate and may lead to feelings
of guilt.
Question 3 See full question 13s
A boy, age 4, begins to use curse words. Concerned about this behavior, his parents
ask the nurse how to discourage it. Which advice should the nurse offer?
You Selected:
"Tell him it isn't acceptable and he'll be disciplined if he continues to do it."
Correct response:
"Tell him it isn't acceptable and he'll be disciplined if he continues to do it."
Explanation:
The nurse should advise the parents to tell him it isn't acceptable because by
explaining their objections and expectations, the parents teach the child why the
behavior is unacceptable and help him understand that he must stop it. Telling the
parents to ignore the behavior, or telling the child the behavior makes the parent
angry, wouldn't teach the child that his behavior is inappropriate. Advising the
parents to tell him good little boys don't use curse works would reinforce the
impression that the child is "bad," diminishing his self-image while doing little to
change the objectionable behavior.
Question 4 See full question 19s
When planning care for a child with epiglottiditis, the nurse should assign highest
priority to which nursing diagnosis:
You Selected:
, Ineffective airway clearance
Correct response:
Ineffective airway clearance
Explanation:
Because airway obstruction is a life-threatening complication of epiglottiditis,
Ineffective airway clearance takes highest priority. Fear, Ineffective thermoregulation,
and Risk for disproportionate growth are important but don't take precedence over
Ineffective airway clearance and ensuring airway patency.
Remediation:
Epiglottiditis, pediatric
Question 5 See full question 28s
A nurse discovers a 5-year-old child who's unresponsive, apneic, and pulseless. The
correct sequence of events that should follow is:
You Selected:
call for help, open the airway, provide two rescue breaths, and begin
compressions at a rate of 100 per minute.
Correct response:
call for help, open the airway, provide two rescue breaths, and begin
compressions at a rate of 100 per minute.
Explanation:
The nurse should call for help, open the airway, provide two rescue breaths, begin
compressions at a rate of 100 per minute, give two breaths for every 30
compressions, continue for approximately 2 minutes, and reassess. This is the
accepted sequence defined by the Canadian Heart and Stroke Foundation for one-
rescuer child cardiopulmonary resuscitation (CPR). Calling for help should be the
first action to ensure that assistance arrives quickly. The accepted sequence of
events for one-rescuer adult CPR is to call for help, open the airway, provide two
rescue breaths, begin compressions at a rate of 100 per minute, give two breaths
, for every 30 compressions, continue for approximately 2 minutes, and reassess. As
soon as unresponsiveness, breathlessness, or lack of pulse has been established,
CPR should begin immediately.
Remediation:
Cardiopulmonary resuscitation (CPR), one-person, child
Code management
Question 6 See full question 11s
After teaching the parents about the cause of ringworm of the scalp (tinea capitis),
which statement by a parent indicates successful teaching?
You Selected:
"It's a fungal infection of the scalp."
Correct response:
"It's a fungal infection of the scalp."
Explanation:
Ringworm of the scalp is caused by a fungus of the dermatophyte group of the
species. Overexposure to the sun would result in sunburn. Mites, such as chiggers
or ticks, produce bites on the skin, resulting in inflammation. An allergic reaction
commonly is manifested by hives, rash, or anaphylaxis.
Question 7 See full question 15s
A 4-year-old child with hydrocephalus is scheduled to have a ventroperitoneal
shunt in the right side of the head. When developing the child’s postoperative plan
of care, the nurse should place the preschooler in which position immediately
after surgery?
You Selected:
on the left side, with the head of the bed elevated
Correct response:
Question 1 See full question 10s
A preschool-age child with sickle cell anemia is admitted to the health care facility in
vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's
highest priority when caring for this child?
You Selected:
Administering antipyretics as ordered
Correct response:
Providing fluids
Explanation:
During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together
and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the
highest priority is providing I.V. and oral fluids, which promotes hemodilution and
aids the free flow of RBCs through blood vessels. The client must be kept away
from known infection sources but doesn't require protective isolation. Warm
compresses may be applied to painful joints to promote comfort; cool compresses
would cause vasoconstriction, which exacerbates sickling. Antipyretics may be
administered to reduce fever but don't play a crucial role in resolving the crisis.
Remediation:
Anemia, sickle cell, pediatric
Question 2 See full question 24s
A preschool-age child refuses to take ordered medication. Which nursing strategy is
most appropriate?
You Selected:
Showing trust in the child's ability to cooperate even with an unpleasant
procedure
Correct response:
, Showing trust in the child's ability to cooperate even with an unpleasant
procedure
Explanation:
To gain a preschooler's cooperation, the most appropriate strategy is for the nurse
to show trust and express faith in the child's ability to cooperate even with an
unpleasant procedure. Hiding the medication in milk may foster mistrust. The
nurse should provide simple, not detailed, explanations and should use terms the
child can understand. Shaming the child is inappropriate and may lead to feelings
of guilt.
Question 3 See full question 13s
A boy, age 4, begins to use curse words. Concerned about this behavior, his parents
ask the nurse how to discourage it. Which advice should the nurse offer?
You Selected:
"Tell him it isn't acceptable and he'll be disciplined if he continues to do it."
Correct response:
"Tell him it isn't acceptable and he'll be disciplined if he continues to do it."
Explanation:
The nurse should advise the parents to tell him it isn't acceptable because by
explaining their objections and expectations, the parents teach the child why the
behavior is unacceptable and help him understand that he must stop it. Telling the
parents to ignore the behavior, or telling the child the behavior makes the parent
angry, wouldn't teach the child that his behavior is inappropriate. Advising the
parents to tell him good little boys don't use curse works would reinforce the
impression that the child is "bad," diminishing his self-image while doing little to
change the objectionable behavior.
Question 4 See full question 19s
When planning care for a child with epiglottiditis, the nurse should assign highest
priority to which nursing diagnosis:
You Selected:
, Ineffective airway clearance
Correct response:
Ineffective airway clearance
Explanation:
Because airway obstruction is a life-threatening complication of epiglottiditis,
Ineffective airway clearance takes highest priority. Fear, Ineffective thermoregulation,
and Risk for disproportionate growth are important but don't take precedence over
Ineffective airway clearance and ensuring airway patency.
Remediation:
Epiglottiditis, pediatric
Question 5 See full question 28s
A nurse discovers a 5-year-old child who's unresponsive, apneic, and pulseless. The
correct sequence of events that should follow is:
You Selected:
call for help, open the airway, provide two rescue breaths, and begin
compressions at a rate of 100 per minute.
Correct response:
call for help, open the airway, provide two rescue breaths, and begin
compressions at a rate of 100 per minute.
Explanation:
The nurse should call for help, open the airway, provide two rescue breaths, begin
compressions at a rate of 100 per minute, give two breaths for every 30
compressions, continue for approximately 2 minutes, and reassess. This is the
accepted sequence defined by the Canadian Heart and Stroke Foundation for one-
rescuer child cardiopulmonary resuscitation (CPR). Calling for help should be the
first action to ensure that assistance arrives quickly. The accepted sequence of
events for one-rescuer adult CPR is to call for help, open the airway, provide two
rescue breaths, begin compressions at a rate of 100 per minute, give two breaths
, for every 30 compressions, continue for approximately 2 minutes, and reassess. As
soon as unresponsiveness, breathlessness, or lack of pulse has been established,
CPR should begin immediately.
Remediation:
Cardiopulmonary resuscitation (CPR), one-person, child
Code management
Question 6 See full question 11s
After teaching the parents about the cause of ringworm of the scalp (tinea capitis),
which statement by a parent indicates successful teaching?
You Selected:
"It's a fungal infection of the scalp."
Correct response:
"It's a fungal infection of the scalp."
Explanation:
Ringworm of the scalp is caused by a fungus of the dermatophyte group of the
species. Overexposure to the sun would result in sunburn. Mites, such as chiggers
or ticks, produce bites on the skin, resulting in inflammation. An allergic reaction
commonly is manifested by hives, rash, or anaphylaxis.
Question 7 See full question 15s
A 4-year-old child with hydrocephalus is scheduled to have a ventroperitoneal
shunt in the right side of the head. When developing the child’s postoperative plan
of care, the nurse should place the preschooler in which position immediately
after surgery?
You Selected:
on the left side, with the head of the bed elevated
Correct response:
