QUESTIONS AND ANSWERS WITH RATIONALES.LATEST
UPDATE 2023
• A nurse is assessing the pain level of a 3 year old
toddler. Which of thefollowing assessment scales should
the nurse use?
• FACES
• Numeric
• CRIES
• Visual analog✔✔✔ A. The nurse should use the FACES pain
rating scale for pediatric clients who are 3 years old and older.
This scale allows the toddler to pointto the face that depicts their
current level of pain. The nurse can then determine the need for
pain management.
• A nurse is planning an educational program to teach
parents about pro-tecting their children from sunburns.
Which of the following instructions should the nurse plan
to include?
,• "allow your child to play outside during the hours
between 10:00am and2:00pm."
• "choose a waterproof sunscreen with a minimum SPF of
15."
• "dress you child in loose weave polyester fabric prior to
sun exposure."
• "reapply sunscreen every 4 hours."✔✔✔ B. The nurse
should instruct parents to apply a waterproof sunscreen with a
minimum SPF of 15 for children. The parents should apply the
sunscreen prior to sun exposure to reduce the risk of sunburn.
• A nurse is performing hearing screenings for children
at a communityhealth fair. Which of the following
children should the nurse refer to a provider for a more
extensive hearing evaluation?
• an 18 month old toddler who has unintelligible speech
• a 3 month old infant who has exaggerated startle
response
• a 4 year old preschooler who prefers playing with others
rather than alone
• an 8 month old infant who is not yet making babbling
sounds✔✔✔ D. The nurse should refer an infant who is not
,making babbling sounds by the age of 7 months to a provider for
a more extensive evaluation of hearing.
• A nurse in an emergency department is assessing a 3
month old infant who has rotavirus and is experiencing
acute vomiting and diarrhea. Which ofthe following
manifestations should the nurse identify as an indication
thatthe infant has moderate to severe dehydration?
• HR 124
• increased tear production
• sunken anterior fontanel
• capillary refill 2 seconds✔✔✔ C. The nurse should recognize
that a sunken anteriorfontanel is an indication of moderate to
severe dehydration due to the acute loss of fluid.
• A nurse is providing teaching to the family of a school-
age child who hasjuvenile idiopathic arthrisis. Which of the
following instructions should thenurse include in the
teaching?
• "limit movement of the child's large joints"
• "encourage the child to perform independent self-care."
, • "provide the child with a soft mattress for sleeping."
• "schedule a 2 hour daily nap for the child in the
afternoon."✔✔✔ B. The nurse should teach the family the
importance of encouraging the child to perform independent
self-care. This will minimize the child's pain while maximizing
mobility.Encouraging and praising the child's efforts for
independence will also increase their self-esteem.
• A nurse is planning care for a school age child who has a
tunneled central venous access device. Which of the
following interventions should the nurseinclude in the plan?
• use sterile scissors to remove the dressing from the site
• irrigate each lumen weekly with 10 ml of 0.9% sodium
chloride solutionwhen not in use
• access the site suing a noncoring angle needle
• use a semipermeable transparent depressing to cover the
site✔✔✔ D. The nurse should cover the site with a
semipermeable transparent dressing to reduce the risk of
infection.