NSG6435 Final 2 Exam 2022/2023 with complete solutions

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? - ANSWER introduce self What action is most likely to encourage parents to talk about their feelings related to their child's illness? - ANSWER Use open-ended questions. What is the single most important factor to consider when communicating with children? - ANSWER The child's developmental level What is an important consideration for the nurse who is communicating with a very young child? - ANSWER Use transition objects such as a doll. When introducing hospital equipment to a preschooler who seems afraid, the nurse's approach should be based on which principle? - ANSWER The child may think the equipment is alive. Which age group is most concerned with body integrity? - ANSWER School-age child An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: - ANSWER Explain in simple terms how it works. When the nurse interviews an adolescent, it is especially important to: - ANSWER Allow an opportunity to express feelings. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful? - ANSWER Ask the child to draw a picture. The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? - ANSWER Ask adolescent, "Why did you come here today?" Where in the health history should the nurse describe all details related to the chief complaint? - ANSWER Present illness 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 heading? - ANSWER Birth history 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 because these milestones are: - ANSWER An important part of the child's past growth and development The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: - ANSWER Ask her, "Are you having sex with anyone?" When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: - ANSWER May provide sufficient amino acids. Which parameter correlates best with measurements of the body's total protein stores? - ANSWER Upper arm circumference An appropriate approach to performing a physical assessment on a toddler is to: - ANSWER Use minimal physical contact initially. With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight? - ANSWER 85th percentile The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that: - ANSWER The NCHS charts are accurate for U.S. African-American children. Which tool measures body fat most accurately? - ANSWER Calipers By what age do the head and chest circumferences generally become equal? - ANSWER 1 to 2 years The earliest age at which a satisfactory radial pulse can be taken in children is: - ANSWER 2 years Where is the best place to observe for the presence of petechiae in dark-skinned individuals? - ANSWER Oral mucosa When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: - ANSWER Infection or inflammation close to the site. 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. The most appropriate action is to: - ANSWER Refer for immediate medical evaluation. The nurse should expect the anterior fontanel to close at age: - ANSWER 12 to 18 months 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: - ANSWER A normal finding. Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? - ANSWER 3 to 4 months The most frequently used test for measuring visual acuity is the: - ANSWER Snellen letter chart. The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target? - ANSWER 3 to 4 months The appropriate placement of a tongue blade for assessment of the mouth and throat is the: - ANSWER Side of the tongue. What type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? - ANSWER Vesicular What term is used to describe breath sounds that are produced as air passes through narrowed passageways? - ANSWER Wheezes The nurse must assess a child's capillary filling time. This can be accomplished by: - ANSWER Palpating the skin to produce a slight blanching. What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? - ANSWER murmur Examination of the abdomen is performed correctly by the nurse in this order: - ANSWER inspection, auscultation, and palpation The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. The rationale for this position is that: - ANSWER It prevents cremasteric reflex. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: - ANSWER Normal because the lower back and leg muscles are not yet well developed. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for: - ANSWER Cerebellar function. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? Choose all that apply. - ANSWER The cuff bladder width is approximately 40% of the circumference of the upper arm. The cuff bladder length covers 80% to 100% of the circumference of the upper arm. Which data would be included in a health history? Choose all that apply - ANSWER Nutritional assessment Family medical history Sexual history Review of systems Which statement best describes the infant's physical development? - ANSWER Birth weight doubles by age 5 months and triples by age 1 year. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately: - ANSWER 15 pounds The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as - ANSWER A normal finding. Because the anterior fontanel normally closes between ages 12 and 18 months, By what age does the posterior fontanel usually close? - ANSWER 6 to 8 weeks The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stool. The nurse bases her explanation on knowing that: - ANSWER This is normal because of the immaturity of digestive processes at this age. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as: - ANSWER Normal development. In terms of fine motor development, the infant of 7 months should be able to: - ANSWER Transfer objects from one hand to the other. In terms of gross motor development, what would the nurse expect a 5-month-old infant to do? - ANSWER Roll from abdomen to back At which age can most infants sit steadily unsupported? - ANSWER 8 months By what age should the nurse expect that an infant will be able to pull to a standing position? - ANSWER 11 to 12 months they can pull themselves up by 9 months According to Piaget, the 6-month-old infant would be in what stage of the sensorimotor phase - ANSWER Secondary circular reactions What behavior indicates that an infant has developed object permanence? - ANSWER Actively searches for a hidden object Most infants begin to fear strangers at age: - ANSWER 6 months The nurse is interviewing the father of 10-month-old Megan. She is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says "No" firmly and removes her from near the outlet. The nurse should use this opportunity to teach the father that Megan: - ANSWER Is old enough to understand the word "No." Sara, age 4 months, was born at 35 weeks' gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. The nurse should explain that: - ANSWER Infants' temperaments are part of their unique characteristics. What information could be given to the parents of a 12-month-old child regarding appropriate play activities for this age? - ANSWER Give large push-pull toys for kinetic stimulation. An appropriate play activity for a 7-month-old infant to encourage visual stimulation is: - ANSWER Playing peek-a-boo. The best play activity for a 6-month-old infant to provide tactile stimulation is to: - ANSWER Allow to splash in bath. At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? - ANSWER 2 months Latasha is a breastfed infant being seen in the clinic for her 6-month checkup. Her mother tells the nurse that she recently began to suck her thumb. The best nursing intervention is to: - ANSWER Reassure the mother that this is very normal at this age. Austin, age 6 months, has six teeth. The nurse should recognize that this is: - ANSWER Earlier-than-normal tooth eruption. The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, high-top shoes. The nurse should explain that: - ANSWER Soft and flexible shoes are generally better. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should recommend that the infant be given: - ANSWER Commercial iron-fortified formula. When is the best age for solid food to be introduced into the infant's diet? - ANSWER 4 to 6 months The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. The nurse should recommend to: - ANSWER Always leave bottle top uncovered to allow heat to escape. Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on knowing that: - ANSWER This is a common and accepted practice, especially in some cultural groups. The parent of 2-week-old Sarah asks the nurse if Sarah needs fluoride supplements because she is exclusively breastfed. The nurse's best response is: - ANSWER She may need to begin taking them at age 6 months." A mother tells the nurse that she doesn't want her infant immunized because of the discomfort associated with injections. The nurse should explain that: - ANSWER A topical anesthetic, eutectic mixture of local anesthetic (EMLA), can be applied before injections are given. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The nurse's reply should be based on knowing that: - ANSWER Hot dogs must be cut into small, irregular pieces to prevent aspiration. The clinic is lending a federally approved car seat to an infant's family. The nurse should explain that the safest place to put the car seat is: - ANSWER Rear facing in back seat. Pacifiers can be extremely dangerous because of the frequency of use and the intensity of the infant's suck. In teaching parents about appropriate pacifier selection, the nurse should explain that a pacifier should have which characteristics? Choose all that apply - ANSWER Easily grasped handle One-piece construction Sturdy, flexible materia In terms of gross motor development, what would the nurse expect a 5-month-old infant to do? Choose all that apply. - ANSWER Roll from abdomen to back Put feet in mouth when supine A chest x-ray film is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the radiograph show about the heart?" The nurse's response should be based on knowledge that the x-ray film will: - ANSWER Provide a permanent record of heart size and configuration. A complication that may occur after a cardiac catheterization is: - ANSWER Cardiac arrhythmia. José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: - ANSWER Adapted to his level of development so that he can understand. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: - ANSWER Apply direct pressure above the catheterization site. Which defect results in increased pulmonary blood flow? - ANSWER Atrial septal defect Which structural defects constitute tetralogy of Fallot? - ANSWER Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy What is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? - ANSWER Congestive heart failure A clinical manifestation of the systemic venous congestion that can occur with congestive heart failure is: - ANSWER Peripheral edema. A beneficial effect of administering digoxin (Lanoxin) is that it: - ANSWER Decreases edema. Which drug is an angiotensin-converting enzyme (ACE) inhibitor? - ANSWER Captopril (Capoten) A common sign of digoxin toxicity is: - ANSWER vomiting The parents of a young child with congestive heart failure tell the nurse that they are "nervous" about giving digoxin. The nurse's response should be based on knowing that: - ANSWER Parents must learn specific, important guidelines for administration of digoxin. As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: - ANSWER Potassium. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to - ANSWER Place the child in the knee-chest position The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important objective to decrease this risk is to: - ANSWER Prevent dehydration. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on knowing that: - ANSWER The child needs opportunities to play with peers. When preparing a school-age child and the family for heart surgery, the nurse should consider: - ANSWER Letting child hear the sounds of an electrocardiograph monitor. Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7° C (101° F). The nurse should: - ANSWER Report findings to physician. An important nursing consideration when suctioning a young child who has had heart surgery is to: - ANSWER Administer supplemental oxygen before and after suctioning The nurse is caring for a child after heart surgery. What should he or she do if evidence is found of cardiac tamponade? - ANSWER Immediately report this to the physician. An important nursing consideration when chest tubes will be removed from a child is to: - ANSWER Administer analgesics before procedure. The most common causative agent of bacterial endocarditis is: - ANSWER Streptococcus viridans. What painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? - ANSWER Osler nodes The primary nursing intervention to prevent bacterial endocarditis is to: - ANSWER Counsel parents of high-risk children about prophylactic antibiotics. A common, serious complication of rheumatic fever is: - ANSWER Cardiac valve damage. A major clinical manifestation of rheumatic fever is: - ANSWER Polyarthritis, is swollen, hot, red, and painful joints. The affected joints will change every 1 to 2 days. Primarily the large joints are affected When discussing hyperlipidemia with a group of adolescents, the nurse should explain that high levels of what substance are thought to protect against cardiovascular disease? - ANSWER High-density lipoproteins (HDLs). The leading cause of death after heart transplantation is: - ANSWER rejection When caring for the child with Kawasaki disease, the nurse should know that: - ANSWER Therapeutic management includes administration of gamma globulin and aspirin. High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The One of the most frequent causes of hypovolemic shock in children is: - ANSWER blood loss