During assessment of a child with celiac disease, the nurse should most likely note which physical finding?

You selected: protuberant abdomen

A toddler is admitted to the facility with nephrotic syndrome. The nurse carefully monitors the toddler's fluid
intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most
likely to see?
You selected: Proteinuria
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever. What
would be the best option?
You selected: Allow the mother to hold the child and give the medication.
When preparing a 3-year-old child to have blood specimens drawn for laboratory testing, the nurse should:
You selected: provide verbal explanations about what will occur.
Incorrect
Correct response:
use distraction techniques during the procedure.
Explanation:
A 3-year-old child responds best to distraction during a procedure because of the typical level of cognitive
development of a 3-year-old and the fear of painful events. Preparation for the procedure should be done
immediately beforehand, so that the child will not become too frightened. A 3-year-old is not concerned about
the why of the procedure but about whether the procedure will hurt. This child is too young for verbal
explanations alone because of the limited verbal abilities at this age and the fear of a painful event
The parent of a young child diagnosed with low-dose lead exposure asks about long-term effects. Which
conditions should the nurse mention as possible long-term effects to this parent? Select all that apply.
You selected: impulsiveness
seizures
Incorrect
Correct response:
hyperactivity
aggression
impulsiveness
Explanation:
The neurologic system can be affected and cause long-term consequences in a young child exposed to lead.
Common behavioral effects include hyperactivity, impulsivity, and aggression. Seizures may occur in a child
with high-dose lead exposure. Depression is not usually associated with lead exposure.
A 30-month-old toddler is being evaluated for a ventricular septal defect (VSD). Identify the area where a VSD
occurs.
(see full question)
A 3-year-old child receiving chemotherapy after surgery for a Wilms' tumor has
developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room.
Which food would not be appropriate for this child?
You selected: french fries
Incorrect
Correct response:
fresh strawberries
Explanation:
When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and vegetables may pose a
health risk due to possible bacterial contamination. All other foods are either cooked or pasteurized and would
not produce a health risk.
When performing a physical assessment on an 18-month-old child, which measure would be best?

You selected: Assess motor function by having the child run and walk.
Incorrect
Correct response:
Have a parent hold the toddler.
Explanation:
The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the
toddler.
Assessment should begin with noninvasive assessments first while the child is quiet. Typically, these include
assessments of the cardiac and respiratory systems. The ears and throat are typically examined last.
Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with
noninvasive assessments first while the child is quiet.
Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.
What advice should a nurse give to the parents of a 2-year-old child who frequently throws temper tantrums?
You selected: Move the toddler to a different setting.
Incorrect
Correct response:
Ignore the behavior when it happens.
Explanation:
Ignoring tantrums is the best advice because paying attention to the undesirable behavior can reinforce it.
Changing settings can actually increase the tantrum behavior. Allowing the toddler more choices may also
increase tantrum behavior if the toddler is unable to follow through with choices. It's ill-advised to give into the
toddler's demands because doing so only promotes tantrum behavior.
(see full question)
A nurse is leading a group of parents of toddlers in a discussion on home safety. The
nurse should emphasize which fact?
You selected: A toddler's risk of injury is the same as that of an adult.
Incorrect
Correct response:
Most toddler deaths are accidental.
Explanation:
Most toddler deaths are accidental. Many injuries or deaths in this age-group result from fire, drowning, motor
vehicle accidents, and firearms. Toddlers don't generally overdose on medications, although this situation could
happen if a toddler were given too much medication in the home or hospital setting. A child must be older than
age 12 months and weigh more than 20 lb (9.1 kg) to ride in a front-facing car seat. Toddlers are at higher risk
for injury than adults because of their developmental level and their limited ability to distinguish right from
wrong and to recognize danger signs
A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When
preparing the child's room, the nurse anticipates using which traction system?
You selected: Bryant's traction
Correct
Explanation:
Anticipating Bryant's traction is correct because this type of traction is used to treat femoral fractures or
congenital hip dislocation in children younger than age 2 who weigh less than 30 lb (13.6 kg). Buck's extension
traction is skin traction used for short-term immobilization or to correct bone deformities or contractures.
Overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat
femoral fractures in children older than age 2.
A nurse is caring for a toddler who has just been immunized. When teaching the child's parents about potential
adverse effects, the nurse should instruct the parents to immediately report:

You selected: local swelling at the injection site.

Incorrect
Correct response:
generalized urticaria.
Explanation:
The nurse should instruct parents to immediately report generalized urticaria because it can herald the onset of a
life-threatening episode. A child may experience some pain, redness at the sight, localized swelling, or mild
temperature elevation; however, these reactions can be treated symptomatically and aren't life-threatening.
A 2-year-old child is brought to the emergency department with suspected croup. Which assessment finding
reflects increasing respiratory distress?
You selected: Decreased level of consciousness (LOC)
Incorrect
Correct response:
Intercostal retractions
Explanation:
Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal
retractions, and cyanosis. Bradycardia, LOC, and flushed skin aren't signs of increasing respiratory distress.
The nurse is caring for a young child who has been admitted to the hospital with pertussis. To prevent the spread
of the infection, which of the following is the most important action of the nurse?
You selected: Provide masks for everyone entering the room.
When developing the plan of care for a toddler who has taken an acetaminophen overdose, which intervention
should the nurse expect to include as part of the initial treatment?
You selected: gastric lavage
Correct
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V.
tubing becomes disconnected from the catheter. What should the nurse do first?
You selected: Position the child on the side.
Incorrect
Correct response:
Clamp the catheter.
When planning home care for a 3-year-old child with eczema, what should the nurse teach the mother to remove
from the child's environment at home?
You selected: metal toy trucks
Incorrect
Correct response:
stuffed animals
Explanation:
For the child with eczema, which is commonly related to an allergic response, stuffed animals should be
avoided because they tend to collect dust and are difficult to clean.
A nurse should begin screening for lead poisoning when a child reaches which age?
You selected: 24 months
Incorrect
Correct response:
12 months
Explanation:
The nurse should start screening a child for lead poisoning at age 12 months and perform repeat screenings at
24 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron
supplementation, should be screened for iron deficiency anemia at age 6 months. Regular dental visits should
begin at age 24 months.

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to
take to ensure the safety of the child?
You selected: Maintain a tidy environment around the child.
Correct
Explanation:
Visually impaired children explore their environment by feel. A tidy and organized environment can support this
and promote the childs safety. It is a priority to make sure all items that could potentially injure the child are
removed from the environment. This includes meal trays and supplies for procedures.
(see full question)
A young child who has been sexually abused has difficulty putting feelings into words.
Which approach should the nurse employ with the child?
You selected: engaging in play therapy
Correct
Explanation:
The dolls and toys in a play therapy room are useful props to help the child remember situations and
reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words.
Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic,
having the abuser see the pictures is usually threatening for the child. Reporting abuse to authorities is
mandatory, but does not help the child express feelings
(see full question)
For a child with a Wilms' tumor, which preoperative nursing intervention takes highest
priority?
You selected: Restricting oral intake
Incorrect
Correct response:
Avoiding abdominal palpation
Explanation:
Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most
important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake
and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher
priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.
When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of
care. According to Erikson, offering choices helps the child achieve:
You selected: initiative.
Incorrect
Correct response:
autonomy.
Explanation:
According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and
doubt. Offering the child choices about some aspects of care encourages autonomy. An infant is at the stage of
trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt
The mother of a 2-year-old is concerned because the child's right eye seems to turn in toward his nose when he
is tired. The nurse should:
You selected: Advise the mother to continue to watch his eyes closely and if the problem persists to call the
clinic.
Incorrect
Correct response:
Test the child with the cover-uncover test and refer the mother and child to an
ophthalmologist if the test is abnormal.
Explanation:

Strabismus is diagnosed through observation and use of the corneal light reflex test. The cover-uncover test will
reveal movement of the affected eye when the unaffected eye is covered, indicating abnormal fixation of the
affected eye. The child should be referred to an ophthalmologist as soon as possible so that the correct vision in
the affected eye can be restored. It is never normal for one eye to turn inward or outward even if the child is
tired. If this condition is not corrected early, blindness can result in the unaffected eye due to the brain
suppressing the double vision. Thus, telling the mother to watch the child and call later with concerns is not an
appropriate response. The child will not grow out of this type of condition and may need surgery, an eye patch,
daily exercises, or a combination of these interventions.
Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused?
You selected: clinging to the parent during the examination
Incorrect
Correct response:
absence of crying during the examination
Explanation:
Children who are being abused may demonstrate behaviors such as withdrawal, apparent fear of parents, and
lack of an appropriate reaction, such as crying and attempting to get away when faced with a frightening event
(an examination or procedure)
When teaching a mother of a 17-month-old about toilet training, which instruction would initially be most
appropriate?
You selected: Remove the diaper and use training pants to begin the process.
Incorrect
Correct response:
Be sure the child is ready before starting to toilet train.
Explanation:
All of the instructions are appropriate, but knowing whether the child is ready to toilet train is initially most
appropriate. Many 17-month-olds do not have the neuromuscular control to be able to be trained. Waiting a few
more months until the child is closer to age 2 years allows the child to develop more control. The mother should
be taught the signs of readiness for toilet training.
A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the
tissues. Which measure should the nurse anticipate including in the child's plan of care?
You selected: Maintain strict bed rest.
Incorrect
Correct response:
Weigh the child before breakfast.
Explanation:
The best indicator of fluid balance is weight. Therefore, daily weight measurements help determine fluid losses
and gains. Although limiting visitors to 2 to 3 hours per day or maintaining strict bed rest would help to ensure
that the child gets adequate rest, this is unrelated to the childs fluid balance. In nephrotic syndrome, urine is
tested for protein, not specific gravity
(see full question)
A 2-year-old child with a low blood level of the immunosuppressive drug cyclosporine
comes to a liver transplant clinic for her appointment. The mother says the child hasn't been vomiting and hasn't
had diarrhea, but she admits that her daughter doesn't like taking the liquid medication. Which statement by the
nurse is most appropriate?
You selected: "Insert a nasogastric (NG) tube and administer the medication using the tube as ordered by the
physician."
Incorrect
Correct response:
"Offer the medication diluted with chocolate milk or orange juice to make it more
palatable."
Explanation:

Because liquid cyclosporine has a very unpleasant taste, diluting it with chocolate milk or orange juice will
lessen the strong taste and help the child take the medication as ordered. It is not acceptable to miss a dose
because the drug's effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level.
Cyclosporine should not be given by NG tube because it adheres to the plastic tube and, thus, all of the drug
may not be administered. Taking the medication over a period of time could negatively affect the blood level.
A boy, age 2, is diagnosed with hemophilia, an X-linked recessive disorder. His parents and newborn sister are
healthy. The nurse explains how the gene for hemophilia is transmitted. Which statement by the father indicates
an understanding of X-linked recessive disorders?
You selected: "If we have more sons, all of them will have hemophilia."
Incorrect
Correct response:
"Our newborn daughter may be a carrier of the trait."
Explanation:
The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of Xlinked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene
hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring
because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a
50% chance of expressing the trait whereas female offspring are more likely to carry the trait than express it.
These parents may produce offspring who neither express nor carry the trait for hemophilia.
(see full question)
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg.
The nurse should notify the surgeon about which clinical finding?
You selected: a urine output of 60 mL in 4 hours
Incorrect
Correct response:
alterations in levels of consciousness
he nurse is caring for a toddler in contact isolation for respiratory syncytial virus (RSV). In what order from first
to last should the nurse remove personal protective equipment (PPE)? All options must be used.
gloves
gown
goggles
mask
A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept
regarding oral rehydration therapy should the nurse consider?
You selected: A child who has three wet diapers each day isn't considered dehydrated.
Incorrect
Correct response:
Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes.
A nurse is caring for a 14-month-old infant being treated for an upper respiratory infection. The physician
would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should
the nurse obtain consent?
You selected: Call Child Protective Services.
Incorrect
Correct response:
Obtain consent from the foster parents.
Explanation:
Foster parents have the right to consent to medical care of minors in their care
A nurse is providing health teaching about pediatric immunizations to the parents of a child. Which of the
following is the most appropriate information for the nurse to give the parents about immunizations?
You selected: Your child may need medication for a low-grade fever.

The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an elevated serum
potassium level. What is the priority assessment action for the nurse based on the laboratory data?
You selected: Monitor urine output every 4 hours.
Incorrect
Correct response:
Institute telemetry monitoring.
The mother calls the nurse to report that her toddler just been burned on the arm. The nurse should advise the
mother to first:
You selected: pack the arm in ice, and then take the child to the closest emergency department.
Incorrect
Correct response:
run cool water over the burned area, and then wrap it in a clean cloth.
A toddler has a temperature above 101 F (38.3 C). The physician orders acetaminophen, 120 mg suppository,
to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication
rectally if the child has a diagnosis of:
You selected: sepsis.
Incorrect
Correct response:
thrombocytopenia.
Explanation:
A child with thrombocytopenia or neutropenia shouldn't receive rectal medication because of the increased risk
of infection and bleeding that may result from tissue trauma. No contraindications exist for administering rectal
medication to a child with sepsis, leukocytosis, or anemia
When a toddler with croup is admitted to the facility, a physician orders treatment with a mist tent. As the parent
attempts to put the toddler in the crib, the toddler cries and clings to the parent. What should the nurse do to
gain the child's cooperation with the treatment?
You selected: Let the toddler sit on the parent's lap next to the mist tent.
Incorrect
Correct response:
Encourage the parent to stand next to the crib and stay with the child
A nurse is auscultating for heart sounds in a 2-year-old child. She notes a grade 1 heart murmur. Which
characteristic best describes a grade 1 heart murmur?
You selected: Associated with a precordial thrill
Incorrect
Correct response:
Softer than the heart sounds
Explanation:
A grade 1 heart murmur is commonly difficult to hear and softer than heart sounds. A grade 2 murmur is usually
equal in sound to the heart sounds. A grade 4 murmur is associated with a precordial thrill (a palpable
manifestation associated with a loud murmur). A grade 6 murmur can be heard without a stethoscope
(see full question)
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which
assessment finding should be the nurse's priority concern?
You selected: Tachycardia
Incorrect
Correct response:
Bradycardia
Explanation:
Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An
early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the
nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and
symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos
around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.