A,B & C /VATI RN NURSING CARE OF CHILDREN
REAL EXAM QUESTIONS AND CORRECT
ANSWERS|AGRADE
FORM A
A nurse is providing nutritional teaching to the patents of a child who has acute
glomerulonephritis with pitting edema. Which of the following foods should the
nurse recommend be eliminated from the child's diet? - ANSWER- Hot dogs
Rationale: -Results in edema, HTN, hematuria and proteinuria. Dietary changes
requires limit foods high in sodium because of the edema and HTN. (Hot dogs, or
other processed meats)
A nurse in an emergency department is assessing a 5-year-old child who has a
concussion. Which of the following manifestations should the nurse identify as an
early indication of ICP? - ANSWER- Nausea
Rationale: -Early findings of ICP
A nurse is creating a plan of care for a school-age child who has moderate partial
thickness burns on both lower extremities. Which of the following interventions
should the nurse include in the plan? - ANSWER- Maintain aseptic technique
during the child dressing changes.
Rationale: -To prevent infection. Delayed wound healing can occur due to
infection, which can also cause partial thickness wounds to develop into full
thickness wounds.
A charge nurse on a pediatric unit is reviewing informed consent guidelines with
newly licensed nurse. For which of the following clients should the nurse obtain
informed consent from a guardian? - ANSWER- A 15-year-old client who requires
an open reduction of a fracture.
Rationale: -Sign consent prior to surgical procedures for a minor.
,A nurse is caring for a child who has terminal leukemia. The parents asks the
nurse, "When will we know that our child is nearing the end of their life?" Which
of the following statements should the nurse make? - ANSWER- Your child will
lose movement in their legs.
Rationale: -Lose movement in the lower extremities. This progressive loss of
movement will move up the body as death nears.
A nurse is providing home care instructions to the parents of a child who is in the
edema phase of nephrotic syndrome. Which of the following instructions should
the nurse include in the teaching? - ANSWER- Provide quite activities for the
child.
Rationale: -Provide quite activities, such as reading and coloring, during edema
phase of nephritis to minimize oxygen consumption and preserve energy.
A nurse is assessing a 2-year-old child following a surgical procedure. Which of
the following pain tools should the nurse use? - ANSWER- Face, Legs, Activity,
Cry Consolability (FLACC) scale.
Rationale: -The FLACC scale is used for infants and children from 2 months to 7
years.
A nurse is providing discharge teaching to the parents of a school age child who
has epilepsy and a new prescription for phenytoin extended release capsules.
Which of the following instructions should the nurse include in the teaching? -
ANSWER- Encourage the child to brush their teeth after each meal.
Rationale: - Dental hygiene, this medications can cause gingival hyperplasia, and
good oral hygiene reduces the risk of this occurring.
A nurse is caring for a 6 month old infant who has acute vomiting and diarrhea.
Which of the following manifestations should the nurse identify as an indication of
moderate hypovolemia? - ANSWER- Tachypnea
Rationale: -A hypovolemia worsens, breathing becomes hyperpneic.
A nurse is caring for a toddler who is experiencing hyperglycemia. Which of the
following manifestations should the nurse expect? - ANSWER- Lethargic mood.
, Rationale: -Will be irritable and have a labile mood.
A nurse is providing discharge teaching to the parent of a 5-year-old child who has
leukemia and is receiving chemotherapy. Which of the following statements by the
parent indicates an understanding of the teaching? - ANSWER- I will make sure to
inspect my son's mouth every day for sores.
Rationale: -Increase risk for mucositis, therefore, the parent should inspect the
mouth daily for lesions or ulcerations and report these to the provider. Open
lesions can become infected in the child who is immunocompromised.
A home health nurse is developing a plan of care for the parents of a toddler who
has hemophilia A. Which of the following instructions should the nurse include? -
ANSWER- Place knee pads on the child.
Rationale: -Take measures to make the environment safe. This can include
measures such as installing carpet over ceramic tiled floors or placing knee and
elbow pads on the child to protect the Childs joints form injury and bleeding.
A nurse is planning care for a child who has cerebral palsy and is experiencing
muscle spasms. Which of the following medications should the nurse expect to
administer? - ANSWER- Baclofen
Rationale: -Centrally acting skeletal muscle relaxant that will decrease muscle
spasm and sever spasticity.
A nurse is providing discharge teaching to a group of guardians of infants about
home safety. Which of the following statements should the nurse make? -
ANSWER- Keep your infant restrained when they are in a highchair.
Rationale: -Restrain infant while sitting in a highchair using the included straps
with a closure. This will prevent the infant from falling out of the chair and
decrease the risk of injury. Avoid leaving their infant in a highchair unattended
because of the risk of slipping down in the chair and strangling on the safety straps.
A nurse is assessing a 4-year-old child who is 2 days postoperative following
insertion of a ventriculoperitoneal shunt. Which of the following findings is the
nurse's priority? - ANSWER- Lethargy