Chapter 14: Developmentally Appropriate Nursing Care
Across Care Setting
1. 1. On physical assessment of the skin of a patient, the nurse
documents cyanosis. What other related assessment should the nurse
perform?
A. Ask the parent about yellow and orange vegetable intake.
B. Draw blood for hemoglobin, hematocrit, and liver function studies.
C. Palpate all the child's lymph nodes, assessing for enlargement.
D. Take the child's vital signs, including blood pressure and pulse.: D.
Cyanosis may indicate a compromised cardiorespiratory state, and the nurse
should assess measures of cardiac output and respiratory function. Taking vital
signs will give the nurse information about these two systems.
2. 2. A nursing manager is concerned about frequent errors on the
pediatric unit and wants to decrease them. What action by the manager is
best?
A. Have two nurses verify all new orders when they are written.
B. Use barcode authentication.
C. Provide remedial education to nurses who make errors.
D. Require charge nurses to verify care plans with staff nurses.: B. Use of
improved technology with barcode authentication will help to limit the amount of
medication errors.
3. 3. A nurse is assessing a school-age child who complains of stomach aches
after eating. Which question is appropriate for the "D" component of the OLD
CAT mnemonic?
A. "Can you describe how your tummy pain feels?"
B. "Have you tried any over-the-counter drugs?"
C. "How long does the pain last after you eat?"
D. "What day did you first notice the pain?": C. OLD CAT stands for onset,
location, duration, character, aggravating/alleviating factors, and timing. Asking
the child how long the pain lasts reflects duration, or the "D" component.
4. 4. A nurse is assessing a 10-month-old baby's anterior fontanel and finds it
slightly depressed; the fontanel measures 2 inches (5.08 cm). What
conclusion and action are most appropriate?
A. Delayed closing; alert health-care provider.
B. Fontanel is closing; document findings.
C. Large for age; assess for Down's syndrome.
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, Chapter 14: Developmentally Appropriate Nursing Care
Across Care Setting
D. Sign of dehydration; assess fluid status.: D. A depressed fontanel is a sign
of possible dehydration, and the nurse should assess for other signs of fluid
status.
5. 5. The nurse reads in the child's chart that the Hirschberg test demonstrated
displacement of light reflection in one eye. What does this indicate to the
nurse?
A. Color blindness
B. Normal ocular alignment
C. Presence of cataracts
D. Presence of strabismus: D. Ocular alignment is demonstrated through the
Hirschberg test. When a light is shined directly into the child's eyes, the
reflection should fall in the same location on the cornea of both eyes.
Displacement of the corneal light reflection is indicative of strabismus.
6. 6. A nurse is caring for a 5-year-old who broke his arm and is
complaining of pain. What statement by the nurse to the child would be
most helpful?
A. "I bet your arm will stop hurting really soon."
B. "You don't have to stand pain; I can give you medicine."
C. "You didn't do anything wrong that caused the hurt."
D. "Wait until you see the cool cast you are going to get.": C. Children aged 2
to 7 years often view pain as a punishment. The most comforting thing the
nurse can say is to reassure the child that this is not the case.
7. 7. A 66-lb. child complains of mild pain after a procedure. What action by
the nurse is best?
A. Administer 0.3 mg of naloxone (Narcan) every 4 hours orally if needed.
B. Administer 300 mg of acetaminophen (Tylenol) orally and provide a movie
to watch.
C. Administer 450 mg of acetaminophen (Tylenol) orally every 3 hours as
requested.
D. Administer morphine sulfate (Astromorph) 9 mg orally every 4 hours if
needed.: B. For mild pain, acetaminophen and other mild analgesics work well
along with a distraction or other comfort measures. The most appropriate
choice is 300 mg of acetaminophen (within the dose range of 10-15 mg/kg
every 4-6 hours) and a movie to distract the child.
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Across Care Setting
1. 1. On physical assessment of the skin of a patient, the nurse
documents cyanosis. What other related assessment should the nurse
perform?
A. Ask the parent about yellow and orange vegetable intake.
B. Draw blood for hemoglobin, hematocrit, and liver function studies.
C. Palpate all the child's lymph nodes, assessing for enlargement.
D. Take the child's vital signs, including blood pressure and pulse.: D.
Cyanosis may indicate a compromised cardiorespiratory state, and the nurse
should assess measures of cardiac output and respiratory function. Taking vital
signs will give the nurse information about these two systems.
2. 2. A nursing manager is concerned about frequent errors on the
pediatric unit and wants to decrease them. What action by the manager is
best?
A. Have two nurses verify all new orders when they are written.
B. Use barcode authentication.
C. Provide remedial education to nurses who make errors.
D. Require charge nurses to verify care plans with staff nurses.: B. Use of
improved technology with barcode authentication will help to limit the amount of
medication errors.
3. 3. A nurse is assessing a school-age child who complains of stomach aches
after eating. Which question is appropriate for the "D" component of the OLD
CAT mnemonic?
A. "Can you describe how your tummy pain feels?"
B. "Have you tried any over-the-counter drugs?"
C. "How long does the pain last after you eat?"
D. "What day did you first notice the pain?": C. OLD CAT stands for onset,
location, duration, character, aggravating/alleviating factors, and timing. Asking
the child how long the pain lasts reflects duration, or the "D" component.
4. 4. A nurse is assessing a 10-month-old baby's anterior fontanel and finds it
slightly depressed; the fontanel measures 2 inches (5.08 cm). What
conclusion and action are most appropriate?
A. Delayed closing; alert health-care provider.
B. Fontanel is closing; document findings.
C. Large for age; assess for Down's syndrome.
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, Chapter 14: Developmentally Appropriate Nursing Care
Across Care Setting
D. Sign of dehydration; assess fluid status.: D. A depressed fontanel is a sign
of possible dehydration, and the nurse should assess for other signs of fluid
status.
5. 5. The nurse reads in the child's chart that the Hirschberg test demonstrated
displacement of light reflection in one eye. What does this indicate to the
nurse?
A. Color blindness
B. Normal ocular alignment
C. Presence of cataracts
D. Presence of strabismus: D. Ocular alignment is demonstrated through the
Hirschberg test. When a light is shined directly into the child's eyes, the
reflection should fall in the same location on the cornea of both eyes.
Displacement of the corneal light reflection is indicative of strabismus.
6. 6. A nurse is caring for a 5-year-old who broke his arm and is
complaining of pain. What statement by the nurse to the child would be
most helpful?
A. "I bet your arm will stop hurting really soon."
B. "You don't have to stand pain; I can give you medicine."
C. "You didn't do anything wrong that caused the hurt."
D. "Wait until you see the cool cast you are going to get.": C. Children aged 2
to 7 years often view pain as a punishment. The most comforting thing the
nurse can say is to reassure the child that this is not the case.
7. 7. A 66-lb. child complains of mild pain after a procedure. What action by
the nurse is best?
A. Administer 0.3 mg of naloxone (Narcan) every 4 hours orally if needed.
B. Administer 300 mg of acetaminophen (Tylenol) orally and provide a movie
to watch.
C. Administer 450 mg of acetaminophen (Tylenol) orally every 3 hours as
requested.
D. Administer morphine sulfate (Astromorph) 9 mg orally every 4 hours if
needed.: B. For mild pain, acetaminophen and other mild analgesics work well
along with a distraction or other comfort measures. The most appropriate
choice is 300 mg of acetaminophen (within the dose range of 10-15 mg/kg
every 4-6 hours) and a movie to distract the child.
2/6
