NURS366 END TERM EXAM
3/QUESTIONS & ANSWERS A+
When assessing a child's injury if the ED, a nurse suspects physical abuse. Based
on this suspicion, the nurse's primary legal responsibility is:
A: Assist the family in identifying resources for support
B: Report the case in which the abuse is suspected to the local authorities
C: Document the child's physical assessment findings accurately and thoroughly
D: Refer the family to the hospital support group - B: Report the case in which the
abuse is suspected to the local authorities
Nursing care of a child in the hospital with suspected abuse should include:
A: Assign a variety of nurses to the child so that he can get to know and trust the
whole staff
B: Praise the child's ability to minimize feelings of shame and guilt
C: Treat the child as someone with a specific problem, not as an "abuse" victim, to
promote self-esteem and minimize feelings of guilt
D: Talk with and ask question as often as possible to show interest and get to know
the child better - C: Treat the child as someone with a specific problem, not as an
"abuse" victim, to promote self-esteem and minimize feelings of guilt
What should parents understand is one of the most common causes of injury and
death for a 7-month-old infant?
1. Poisoning.
2. Child abuse.
3. Aspiration.
4. Dog bites. - 3. Aspiration.
Which approach should the nurse use to gather information from a child brought to
the ED for suspected child abuse?
1. Promise the child that her parents will not know what she tells the nurse.
2. Promise the child that she will not have to see the suspected abuser again.
3. Use correct anatomical terms to discuss body parts.
4. Tell the child that the abuse is not her fault and that she is a good person. - 4. Tell
the child that the abuse is not her fault and that she is a good person.
A 3-year-old boy has been hospitalized because he fell down the stairs. His mother
is crying and states, "This is all my fault." Which is the nurse's best response?
1. "Accidents happen. You shouldn't blame yourself."
2. "Falls are one of the most common injuries in this age group."
3. "It may be a good idea to put a baby gate on the stairs."
4. "Your son should be proficient at walking down the stairs by now." - 2. "Falls are
one of the most common injuries in this age group."
,Which assessment is most important after any injury in a child?
1. History of loss of consciousness and length of time unconscious.
2. Serial assessments of level of consciousness.
3. Initial neurological assessment.
4. Initial vital signs and oxygen saturation level. - 2. Serial assessments of level of
consciousness.
Which statement most accurately describes child abuse?
1. Intentional physical abuse and neglect.
2. Intentional and unintentional physical and emotional abuse and neglect.
3. Sexual abuse of children, usually by an adult.
4. Intentional physical, emotional, and sexual abuse and neglect. - 4. Intentional
physical, emotional, and sexual abuse and neglect.
What is the most likely cause of a child's illness if it is unexplained, prolonged,
recurrent, and extremely rare, and usually occurs when the mother is present?
1. Genetic disorder.
2. Munchausen syndrome by proxy.
3. Duchenne muscular dystrophy.
4. Syndrome of inappropriate antidiuretic hormone. - 2. Munchausen syndrome by
proxy.
Which statement would be most therapeutic to a child the nurse suspects has been
abused?
1. "Who did this to you? This is not right."
2. "This is wrong that your mother did not protect you."
3. "This is not your fault; you are not to blame for this."
4. "I will not tell anyone." - 3. "This is not your fault; you are not to blame for this."
The mother of a 6-month-old states that since yesterday, the infant cries when
anyone touches her arm. Which would be the priority assessment after the airway,
breathing, and circulation had been assessed and found stable?
1. Ask the mother if she knows what happened.
2. Assess infant for other signs of potential physical abuse.
3. Prepare for radiological diagnostic studies.
4. Establish intravenous access, and draw blood for diagnostic testing. - 1. Ask the
mother if she knows what happened.
Which assessment of an 18-month-old with burns on his feet would cause suspicion
of child abuse?
1. Splash marks on his right lower leg.
2. Burns noted on right arm.
3. Symmetrical burns on both feet.
4. Burns mainly noted on right foot. - 3. Symmetrical burns on both feet.
,Which would be the nurse's priority intervention if a 7-year-old's mother tells the
nurse she has noticed excessive masturbation?
1. Tell her it is normal development for children of this age.
2. Ask the mother if anyone is abusing the child.
3. Talk with the child and find out why she is touching herself down there.
4. Investigate thoroughly the circumstances in which she masturbates. - 2. Ask the
mother if anyone is abusing the child.
Which statement by the mother would lead the nurse to suspect sexual abuse in a 4-
year-old?
1. "She has just started masturbation."
2. "She has lots more temper tantrums."
3. "She now has an invisible friend."
4. "She wants to spend time with her sister." - 2. "She has lots more temper
tantrums."
What would be the priority intervention when a 10-year-old comes to the nurse's
office because of a headache, and the nurse notices various stages of bruising on
the inner aspects of the upper arms?
1. Call her mother and ask if acetaminophen can be given for the headache.
2. Ask the child what happened to her arms, and have her describe the headache.
3. Inquire about the child's headache and bruising on her arms; file mandatory
reporting forms.
4. Call her mother to pick her up from school, and complete required school nurse
visit forms. - 2. Ask the child what happened to her arms, and have her describe the
headache.
Which statement is true of abused children?
1. They will tell the truth if asked about their injuries.
2. They will repeat the same story that their parents tell.
3. They usually are not noted to have any changes in behavior.
4. They will have outgoing personalities and be active in school activities. - 2. They
will repeat the same story that their parents tell.
Which statement is true of shaken baby syndrome?
1. There may be absence of external signs of injury.
2. Shaken babies usually do not have retinal hemorrhage.
3. Shaken babies usually do not have signs of a subdural hematoma.
4. Shaken babies have signs of external head injury. - 1. There may be absence of
external signs of injury.
A 2-month-old infant is brought to the emergency room after experiencing a seizure.
The infant appears lethargic with very irregular respirations and periods of apnea.
The parents report the baby is no longer interested in feeding and before the seizure,
, rolled off the couch. What additional testing should the nurse immediately prepare
for?
1. Computed tomography (CT) scan of the head and dilation of the eyes.
2. Computed tomography (CT) scan of the head and electroencephalogram (EEG).
3. X-rays of the head.
4. X-rays of all long bones. - 1. Computed tomography (CT) scan of the head and
dilation of the eyes.
*A CT scan of the head will reveal trauma. Dilating the eye is performed to check for
retinal hemorrhages that are seen in an infant who has experienced SBS
37. The client comes to the emergency department complaining of pain in the left
lower leg following a puncture wound from a nail in a board. The left lower leg is
reddened with streaks, edematous, and hot to the touch, and the client has a
temperature of 100.8 ̊F. Which condition would the nurse suspect the client is
experiencing?
1. Cellulitis.
2. Lyme disease.
3. Impetigo.
4. Deep vein thrombosis. - 1. Cellulitis.
38. The client comes to the clinic complaining of sudden onset of high fever, chills,
and a headache. The nurse assesses a patchy macular rash on the trunk and a
circular type of rash that looks like an insect bite. Which question would be most
appropriate for the nurse to ask during the interview?
1. "Do you own dogs that stay in the yard?"
2. "Have you been working in your garden lately?"
3. "Have you been deer hunting in the last week?"
4. "Do you use sunscreen when you are outside?" - 3. "Have you been deer hunting
in the last week?"
39. The school nurse is discussing impetigo with the teachers in an elementary
school. One of the teachers asks the nurse, "How can I prevent getting impetigo?"
Which statement would be the most appropriate response?
1. "Wash your hands after using the bathroom."
2. "Do not touch any affected areas without gloves."
3. "Apply a topical antibiotic to your hands."
4. "Keep the child with impetigo isolated in the room." - 2. "Do not touch any affected
areas without gloves."
40. The client is admitted to the medical floor diagnosed with cellulitis of the left arm.
Which assessment data would warrant immediate intervention by the nurse?
1. The client has bilaterally weak radial pulses.
2. The client is able to move the left fingers.
3. The client has a CRT less than 3 seconds.
3/QUESTIONS & ANSWERS A+
When assessing a child's injury if the ED, a nurse suspects physical abuse. Based
on this suspicion, the nurse's primary legal responsibility is:
A: Assist the family in identifying resources for support
B: Report the case in which the abuse is suspected to the local authorities
C: Document the child's physical assessment findings accurately and thoroughly
D: Refer the family to the hospital support group - B: Report the case in which the
abuse is suspected to the local authorities
Nursing care of a child in the hospital with suspected abuse should include:
A: Assign a variety of nurses to the child so that he can get to know and trust the
whole staff
B: Praise the child's ability to minimize feelings of shame and guilt
C: Treat the child as someone with a specific problem, not as an "abuse" victim, to
promote self-esteem and minimize feelings of guilt
D: Talk with and ask question as often as possible to show interest and get to know
the child better - C: Treat the child as someone with a specific problem, not as an
"abuse" victim, to promote self-esteem and minimize feelings of guilt
What should parents understand is one of the most common causes of injury and
death for a 7-month-old infant?
1. Poisoning.
2. Child abuse.
3. Aspiration.
4. Dog bites. - 3. Aspiration.
Which approach should the nurse use to gather information from a child brought to
the ED for suspected child abuse?
1. Promise the child that her parents will not know what she tells the nurse.
2. Promise the child that she will not have to see the suspected abuser again.
3. Use correct anatomical terms to discuss body parts.
4. Tell the child that the abuse is not her fault and that she is a good person. - 4. Tell
the child that the abuse is not her fault and that she is a good person.
A 3-year-old boy has been hospitalized because he fell down the stairs. His mother
is crying and states, "This is all my fault." Which is the nurse's best response?
1. "Accidents happen. You shouldn't blame yourself."
2. "Falls are one of the most common injuries in this age group."
3. "It may be a good idea to put a baby gate on the stairs."
4. "Your son should be proficient at walking down the stairs by now." - 2. "Falls are
one of the most common injuries in this age group."
,Which assessment is most important after any injury in a child?
1. History of loss of consciousness and length of time unconscious.
2. Serial assessments of level of consciousness.
3. Initial neurological assessment.
4. Initial vital signs and oxygen saturation level. - 2. Serial assessments of level of
consciousness.
Which statement most accurately describes child abuse?
1. Intentional physical abuse and neglect.
2. Intentional and unintentional physical and emotional abuse and neglect.
3. Sexual abuse of children, usually by an adult.
4. Intentional physical, emotional, and sexual abuse and neglect. - 4. Intentional
physical, emotional, and sexual abuse and neglect.
What is the most likely cause of a child's illness if it is unexplained, prolonged,
recurrent, and extremely rare, and usually occurs when the mother is present?
1. Genetic disorder.
2. Munchausen syndrome by proxy.
3. Duchenne muscular dystrophy.
4. Syndrome of inappropriate antidiuretic hormone. - 2. Munchausen syndrome by
proxy.
Which statement would be most therapeutic to a child the nurse suspects has been
abused?
1. "Who did this to you? This is not right."
2. "This is wrong that your mother did not protect you."
3. "This is not your fault; you are not to blame for this."
4. "I will not tell anyone." - 3. "This is not your fault; you are not to blame for this."
The mother of a 6-month-old states that since yesterday, the infant cries when
anyone touches her arm. Which would be the priority assessment after the airway,
breathing, and circulation had been assessed and found stable?
1. Ask the mother if she knows what happened.
2. Assess infant for other signs of potential physical abuse.
3. Prepare for radiological diagnostic studies.
4. Establish intravenous access, and draw blood for diagnostic testing. - 1. Ask the
mother if she knows what happened.
Which assessment of an 18-month-old with burns on his feet would cause suspicion
of child abuse?
1. Splash marks on his right lower leg.
2. Burns noted on right arm.
3. Symmetrical burns on both feet.
4. Burns mainly noted on right foot. - 3. Symmetrical burns on both feet.
,Which would be the nurse's priority intervention if a 7-year-old's mother tells the
nurse she has noticed excessive masturbation?
1. Tell her it is normal development for children of this age.
2. Ask the mother if anyone is abusing the child.
3. Talk with the child and find out why she is touching herself down there.
4. Investigate thoroughly the circumstances in which she masturbates. - 2. Ask the
mother if anyone is abusing the child.
Which statement by the mother would lead the nurse to suspect sexual abuse in a 4-
year-old?
1. "She has just started masturbation."
2. "She has lots more temper tantrums."
3. "She now has an invisible friend."
4. "She wants to spend time with her sister." - 2. "She has lots more temper
tantrums."
What would be the priority intervention when a 10-year-old comes to the nurse's
office because of a headache, and the nurse notices various stages of bruising on
the inner aspects of the upper arms?
1. Call her mother and ask if acetaminophen can be given for the headache.
2. Ask the child what happened to her arms, and have her describe the headache.
3. Inquire about the child's headache and bruising on her arms; file mandatory
reporting forms.
4. Call her mother to pick her up from school, and complete required school nurse
visit forms. - 2. Ask the child what happened to her arms, and have her describe the
headache.
Which statement is true of abused children?
1. They will tell the truth if asked about their injuries.
2. They will repeat the same story that their parents tell.
3. They usually are not noted to have any changes in behavior.
4. They will have outgoing personalities and be active in school activities. - 2. They
will repeat the same story that their parents tell.
Which statement is true of shaken baby syndrome?
1. There may be absence of external signs of injury.
2. Shaken babies usually do not have retinal hemorrhage.
3. Shaken babies usually do not have signs of a subdural hematoma.
4. Shaken babies have signs of external head injury. - 1. There may be absence of
external signs of injury.
A 2-month-old infant is brought to the emergency room after experiencing a seizure.
The infant appears lethargic with very irregular respirations and periods of apnea.
The parents report the baby is no longer interested in feeding and before the seizure,
, rolled off the couch. What additional testing should the nurse immediately prepare
for?
1. Computed tomography (CT) scan of the head and dilation of the eyes.
2. Computed tomography (CT) scan of the head and electroencephalogram (EEG).
3. X-rays of the head.
4. X-rays of all long bones. - 1. Computed tomography (CT) scan of the head and
dilation of the eyes.
*A CT scan of the head will reveal trauma. Dilating the eye is performed to check for
retinal hemorrhages that are seen in an infant who has experienced SBS
37. The client comes to the emergency department complaining of pain in the left
lower leg following a puncture wound from a nail in a board. The left lower leg is
reddened with streaks, edematous, and hot to the touch, and the client has a
temperature of 100.8 ̊F. Which condition would the nurse suspect the client is
experiencing?
1. Cellulitis.
2. Lyme disease.
3. Impetigo.
4. Deep vein thrombosis. - 1. Cellulitis.
38. The client comes to the clinic complaining of sudden onset of high fever, chills,
and a headache. The nurse assesses a patchy macular rash on the trunk and a
circular type of rash that looks like an insect bite. Which question would be most
appropriate for the nurse to ask during the interview?
1. "Do you own dogs that stay in the yard?"
2. "Have you been working in your garden lately?"
3. "Have you been deer hunting in the last week?"
4. "Do you use sunscreen when you are outside?" - 3. "Have you been deer hunting
in the last week?"
39. The school nurse is discussing impetigo with the teachers in an elementary
school. One of the teachers asks the nurse, "How can I prevent getting impetigo?"
Which statement would be the most appropriate response?
1. "Wash your hands after using the bathroom."
2. "Do not touch any affected areas without gloves."
3. "Apply a topical antibiotic to your hands."
4. "Keep the child with impetigo isolated in the room." - 2. "Do not touch any affected
areas without gloves."
40. The client is admitted to the medical floor diagnosed with cellulitis of the left arm.
Which assessment data would warrant immediate intervention by the nurse?
1. The client has bilaterally weak radial pulses.
2. The client is able to move the left fingers.
3. The client has a CRT less than 3 seconds.
