Which statement by a mother regarding her 15 month old requires further evaluation

A 3-year-old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child’s sense of autonomy? 1. Allow the child to choose what time to take her oral antibiotics. 2. Allow the child to have a doll for medical play. 3. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe. 4. Allow the child to watch age-appropriate videos.

3. Allowing toddlers to participate in actions of which they are capable is an excellent way to enhance their autonomy.

16. The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse’s best response to the father’s question of what the FLACC scale is? 1. “It estimates a child’s level of pain utilizing vital sign information.” 2. “It estimates a child’s level of pain based on parents’ perception.” 3. “It estimates a child’s level of pain utilizing behavioral and physical responses.” 4. “It estimates a child’s level of pain utilizing a numeric scale from 0 to 5.”

3. The FLACC scale utilizes behavioral and physical responses of the child to measure the child’s level of pain. The scale utilizes facial expression, leg position, activity, intensity of cry, and level of consolability.

19. Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay? 1. “My child is able to stand but is not yet taking steps independently.” 2. “My child has a vocabulary of approximately 15 words.” 3. “My child is still sucking his thumb.” 4. “My child seems to be quite wary of strangers.”

1. The child should be walking indepen - dently by 15 to 18 months. Because this toddler is 18 months and not walking, a referral should be made for a developmental consult. -vocab of an 18-mo should be ~ 10 words

20. The mother of a child 2 years 6 months has arranged a play date with the neighbor and her child 2 years 9 months. During the play date the two mothers should expect that the children will do which of the following? 1. Share and trade their toys while playing. 2. Play with one another with little or no conflict. 3. Play alongside one another but not actively with one another. 4. Only play with one or two items, ignoring most of the other toys.

3. Toddlers engage in parallel play. They often play alongside another child, but they rarely engage in activities with the other child.

21. Which foods would the nurse recommend to the mother of a 2-year-old with anemia? 1. 32 oz of whole cow’s milk per day. 2. Meats, eggs, and green vegetables. 3. Fruits, whole grains, and rice. 4. 8 oz of juice, three times per day.

2. Meat, eggs, and green vegetables are excellent sources of iron. Tip - One of the primary reasons toddlers develop anemia is because they are consuming too much milk, which is limiting their intake of iron-rich foods. Milk is a poor source of iron and should be limited to 24 ounces per day

27. Which nursing action would help foster a hospitalized 3-year-old’s sense of autonomy? 1. Let the child choose what time to take the oral antibiotics. 2. Allow the child to have a doll for medical play. 3. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe. 4. Let the child watch age-appropriate videos.

3. Allowing preschoolers to participate in actions of which they are capable is an excellent way to enhance their autonomy.

28. The best method to explain a procedure to a hospitalized preschool-age child is to: 1. Show the child a pamphlet with pictures showing the procedure. 2. Have the 5-year-old next door tell the 4-year-old about the experience. 3. Demonstrate the procedure on a doll. 4. Show the child a video of the procedure

3. A 4-year-old child understands in very concrete and simple terms. Therefore, medical play is an excellent method for helping to understand the procedure.

A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental mile- stones, what should the nurse caring for the child expect the current weight to be? 1. 16lb 4oz 2. 20lb 5oz 3. 24lb 6oz 4. 32lb 8oz

3. Children should triple their birth weight by 12 months of age.

A 13-year-old boy is hospitalized for a femur fracture. He was hit by a car while he and his friends were racing bikes near a major intersection. The child’s parents are concerned about his judgment. The nurse should tell the parents that the behavior is: 1. Typical of young teens. 2. Related to hormonal surges during adolescence. 3. An isolated incident and will not likely happen again. 4. Related to teen rebellion.

1. The brains of young teens are not completely developed, which often leads to poor judgment and impulse control.

A 13-year-old tells the nurse that he is worried because his breasts are growing. They hurt, and he is embarrassed to take his shirt off during gym class. What should the nurse tell him? 1. “The pediatrician will draw some blood to find out why your breasts are growing.” 2. “It is just a slight hormonal imbalance that can be easily corrected with medication.” 3. “This is a normal condition of puberty that will resolve within a year or two.” 4. “This is a rare finding that occurs in about 5% of boys during puberty.”

3. Gynecomastia and breast tenderness are common for about a third of boys during middle puberty. Gynecomastia usually resolves in 2 years.

A 16-year-old is having a discussion with the nurse about the teen’s recent diagnosis of lupus. In explaining the child’s prognosis, the nurse uses the knowledge that adolescents are: 1. Preoccupied with thoughts of the here and now. 2. Able to understand and imagine possibilities for the future. 3. Capable of thinking only in concrete terms. 4. Overly concerned with past events and relationships.

2. Adolescents are becoming abstract thinkers and are able to imagine possibilities for the future.

A 16-year-old male is hospitalized for cystic fibrosis. He will be an inpatient for 2 weeks while he receives IV antibiotics. Which action taken by the nurse will most enhance his psychosocial development? 1. Fax the teen’s teacher, and have her send in his homework. 2. Encourage the teen’s friends to visit him in the hospital. 3. Encourage the teen’s grandparents to visit frequently. 4. Tell the teen he is free to use his phone to call or text friends.

2. Teens are most concerned about being like their peers. Having the teen’s friends visit will help him feel he is still part of the school and social environment.

A 2-year-old admitted to the hospital 2 days ago has been crying and is inconsolable much of the time. The nurse’s best response to the child’s parents who are concerned about this behavior is that the child is in the: 1. Detachment phase of separation anxiety, which is normal for children during hospitalization. 2. Despair stage of separation anxiety, which is normal for children during hospital- ization. 3. Bargaining stage of separation anxiety, which is normal for children during hospitalization. 4. Protest stage of separation anxiety, which is normal for children during hospital- ization.

4. During the protest stage of separation anxiety, children are often inconsolable, and often cry more than they do when they are at home. These children also frequently ask to go home.

A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 44, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse’s best response is: 1. “Your son’s blood pressure is elevated, but the other vital signs are within the normal range..” 2. “Your son’s temperature is elevated, but the other vital signs are within the normal range..” 3. “Your son’s respiratory rate is elevated, but the other vital signs are within the normal range.” 4. “Your son’s heart rate is elevated, but the other vital signs are within the normal range.”

3. A normal respiratory rate for a child from 3 to 6 years is 20 to 30 breaths per minute.

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, and it may make the parent feel better to know that this is common.

A 3-year-old is attending her grandfather’s funeral. Her parents told her that her grandfather is in heaven with God. Which statement describes a 3-year-old child’s understanding of spirituality? 1. “The body is here with us on Earth, and the spirit is in heaven.” 2. “He is in heaven. Is this heaven?” 3. “The spirit is no longer in his body.” 4. “He won’t need his body in heaven.”

2. Three-year-old children are literal thinkers. The child’s parents told her that Grandpa was in heaven. She sees his body, so she thinks they are all in heaven.

A 3-year-old is hospitalized for an ASD repair. The parents have decided to go home for a few hours to spend time with her siblings. The child asks when her mommy and daddy will be back. The nurse’s best response is: 1. “Your mommy and daddy will be back after your nap.” 2. “Your mommy and daddy will be back at 6:00 p.m.” 3. “Your mommy and daddy will be back later this evening.” 4. “Your mommy and daddy will be back in 3 hours.”

1. Preschoolers understand time in relation to events.

A 4-year-old hospitalized with FTT has orders for daily weights, strict intake and output, and calorie counts. Which action by the nurse would be a concern? 1. The nurse weighs the child every morning after breakfast. 2. The nurse weighs the child with no clothing except for undergarments. 3. The nurse sits with the child while the child eats her meals. 4. The nurse weighs the child using the same scale every morning.

1. The child should be weighed every day on the same scale before eating. Her weight will not be an accurate reflection if she is fed prior to being weighed.

A 5-year-old boy has always been one of the shortest children in class. His mother tells the school nurse that her husband is 6' tall and she is 5'7". What should the nurse tell the child’s mother? 1. He is expected to grow about 3 inches every year from ages 6 to 9 years. 2. He is expected to grow about 2 inches every year from ages 6 to 9 years. 3. He should be seen by an endocrinologist for growth-hormone injections. 4. His growth should be re-evaluated when he is 7 years old.

2. During the school-age years, a child grows approximately 2 inches per year

A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse’s best response is: 1. “At 6 months his weight should be approximately three times his birth weight.” 2. “Each child gains weight at his or her own pace.” 3. “At 6 months his weight should be approximately twice his birth weight.” 4. “At 6 months a child should weigh about 10 lb more than his or her birth weight.”

3. Infants should double their birth weight by 4 to 6 months of age.

A 9-year-old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that says “No boys allowed” printed on it. The child’s parents are concerned that she is excluding their neighbor’s son, and they are upset. What should the school nurse tell the child’s parents? 1. Her behavior is cause for concern and should be addressed. 2. Her behavior is common among school-age children. 3. Her feelings about boys will subside within the next year. 4. They should have their daughter speak with the school counselor.

2. This is common behavior. Girls of 9 and 10 generally prefer to have friends who are of the same gender.

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago. The nurse’s best response to the mother is: 1. “I will let the doctor know, and he will talk with you about possible causes of your infant’s weight loss.” 2. “A weight loss of a few ounces is common among newborns, especially for breast- feeding mothers.” 3. “I can tell you are a first-time mother. Don’t worry; we will find out why she is losing weight.” 4. “Maybe she isn’t getting enough milk. How often are you breastfeeding her?”

2. Newborns can lose up to 10% of their birth weight without concern but should regain their birth weight by 2 weeks of age.

A mother requests that her child receive the varicella vaccine at the 9-month well-child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease. 2. The vaccine cannot be given at that visit. 3. The vaccine will be administered after the physician examines the child. 4. A booster vaccination will be needed at 18 months of age.

2. The nurse should not give the vaccine. The varicella vaccine is not usually administered prior to 1 year of age.

According to developmental theories, which important event is essential to the development of the toddler? 1. The child learns to feed self. 2. The child develops friendships. 3. The child learns to walk. 4. The child participates in being potty-trained.

4. Developmental theorists like Erickson and Freud believe that toilet training is the essential event that must be mastered by the toddler. Tip - Toddlers engage in more parallel play. Building friendships is not common until school age and adolescence.

An 18-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse’s best response is: 1. “We will need to contact your parents to let them know.” 2. “We will not contact your parents regarding this visit.” 3. “Who would you like us to contact about your visit here today?” 4. “We cannot promise that the hospital will not contact your parents.”

2. An adolescent has every right to privacy as long as the situation is not life threatening.

An 8-day-old was admitted to the hospital with vomiting and dehydration. The newborn’s heart rate is 170, respiratory rate is 44, blood pressure is 85/52, and temperature is 99°F (37.2°C). What is the nurse’s best response to the parents who ask if the vital signs are normal? 1. “The blood pressure is elevated, but the other vital signs are within normal limits.” 2. “The temperature is elevated, but the other vital signs are within normal limits.” 3. “The respiratory rate is elevated, but the other vital signs are within normal limits.” 4. “The heart rate is elevated, but the other vital signs are within normal limits.”

4. A normal heart rate for a child from birth to 1 month is 90 to 160.

An adolescent has a diagnosis of new-onset diabetes. What would most influence a teenager’s food choices as he begins to make changes in his diet? 1. Parents and their dietary choices. 2. Cultural background. 3. Peers and their dietary choices. 4. Television and other forms of media influence.

3. As a teen, the child is most influenced by his peers. Teens long to be like others around them.

During an adolescent’s initial physical assessment, the nurse notes signs and symp- toms of nutritional deficit. Which assessment led the nurse to this initial conclusion? 1. Protein level within normal limits. 2. Blood pressure is 110/66. 3. Hair and nails are brittle and dry. 4. Teeth appear to be eroded.

3. Dry and brittle hair and nails are common among people who have a nutritional deficit.

How can the nurse best facilitate the trust relationship between infant and parents while the infant is hospitalized? The nurse should: 1. Encourage the parents to remain at their child’s bedside as much as possible. 2. Keep parents informed about all aspects of their child’s condition. 3. Encourage the parents to hold their child as much as possible. 4. Advise the parents to participate actively in their child’s care.

3. Having parents hold their child while in the hospital is an excellent means of building the trust relationship. Infants are most secure when they are being held, patted, and spoken to.

The mother of 11-year-old fraternal twins tells the nurse at their well-child checkup that she is concerned because her daughter has gained more weight and height than her twin brother. The mother is concerned that there is something wrong with her son. The nurse’s best response is: 1. “I understand your concern. I will talk with the physician, and we can draw some lab work.” 2. “Let me ask you whether your son has been ill lately.” 3. “It is normal for girls to grow a little taller and gain more weight than boys at this age.” 4. “It is normal for you to be concerned, but I am sure your son will catch up with your daughter eventually.”

3. This is the appropriate response. The nurse understands that it is normal for girls to grow taller and gain more weight than boys near the end of middle childhood.

The mother of a 13-year-old girl tells the nurse that she is concerned because her daughter has gained 10 lb since she began puberty. The child’s mother asks the nurse for advice about what to do about her daughter’s weight gain. Which should the nurse do? 1. Provide the child’s mother with some pamphlets on nutrition and healthy eating. 2. Provide the child’s mother with information about a new exercise program for teens. 3. Inform the child’s mother that it is common for teen girls to gain weight during puberty. 4. Inform the child’s mother that her daughter will likely gain another 5 to 10 lb in the next year.

3. The nurse should tell the child’s mother that this is a normal finding in teenage girls as they enter puberty.

The mother of a 15-year-old is frustrated because he spends much of his weekend time sleeping. Which is the nurse’s best response to the mother’s frustration? 1. “Your son may be trying to catch up on the sleep missed during the week.” 2. “Developmental theorists believe that teens require more sleep as they begin to integrate new roles into their lives.” 3. “Teens require more sleep due to the rapid physical growth that is occurring.” 4. “Teens require more sleep due to the increase in their social obligations.”

3. Teens require more sleep due to the rapid physical growth that occurs during adolescence

The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse’s best response? 1. “Babies receive the hepatitis B vaccine only if their mother is hepatitis B–positive.” 2. “The first dose of the hepatitis B vaccine will be given prior to discharge today.” 3. “The first dose of hepatitis B vaccine is given at 1 year of age.” 4. “Babies receive their first hepatitis B vaccine at 6 months of age.”

2. The first dose of hepatitis B vaccine is recommended between birth and 2 months. In most hospitals, newborns are given the vaccine prior to discharge.

The mother of an 11-month-old with iron deficiency anemia tells the nurse that her infant is currently taking iron and a multivitamin. Which statement made by the mother should be of concern to the nurse? 1. “I give the iron and multivitamin at the same time each morning.” 2. “I give the iron and multivitamin in the morning 6-oz bottle.” 3. “I give the iron and multivitamin 2 hours before I feed the morning bottle.” 4. “I give the iron and multivitamin in oral syringes toward the back of the cheek.”

2. Medications should never be mixed in a large amount of food or formula because the parent cannot be sure that the child will take the entire feeding. Formula decreases the absorption of iron.

The mother of an adolescent complains that he has had some recent behavioral changes. He comes home from school every day, closes his door, and refrains from interaction with his family. The nurse’s best response to the mother is: 1. “You should speak with your son and ask him directly what is wrong with him.” 2. “You should set limits with your son and tell him that this is unacceptable behavior.” 3. “Your son’s behavior is abnormal, and he is going to need a psychiatric referral.” 4. “Your son’s behavior is normal. You should listen to him without being judgmental.”

4. The child’s behavior is typical of a teen’s response to developmental and psychosocial changes of adolescence.

The nurse is assessing the pain level in an infant who just had surgery. The infant’s parent asks which vital sign changes are expected in a child experiencing pain. The nurse’s best response is: 1. “We expect to see a child’s heart rate decrease and respiratory rate increase.” 2. “We expect to see a child’s heart rate and blood pressure decrease.” 3. “We expect to see a child’s heart rate and blood pressure increase.” 4. “We expect to see a child’s heart rate increase and blood pressure decrease.”

3. When a child is experiencing pain, the normal physiological response is for the heart rate, respiratory rate, and blood pressure to increase.

The nurse is going to give a 6-month-old a dose of Rocephin IM. What must the nurse do when the 1.5-mL dose arrives from the pharmacy? 1. Administer the injection into the deltoid muscle. 2. Divide the dose into two injections. 3. Administer the injection into the dorsogluteal muscle. 4. Give dose as a single injection into the vastus lateralis muscle.

2. A nurse should not deliver more than 1 mL per IM injection to a 6-month-old. The dorsogluteal muscle should not be used The vastus lateralis is the site of choice for an IM injection for a child 6 months old. However, the injection should not be more than 1 mL for a single injection.

The nurse is instructing a new breastfeeding mother in the need to provide her pre- mature infant with an adequate source of iron in her diet. Which statement reflects a need for further education of the new mother? 1. “I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old.” 2. “My baby will need to have iron supplements introduced when she is 4 months old.” 3. “I will need to add iron supplements to my baby’s diet when she is 2 months old.” 4. “When my baby begins to eat solid foods, I should introduce iron-fortified cereals to her diet.”

3. Premature infants have iron stores from the mother that last approximately 2 months, so it is important to introduce an iron supplement by 2 months of age. Full-term infants have iron stores that last approximately 4 to 6 months. AKA Fetal Hemaglobin.

The nurse realizes that a 5-year-old’s mother needs further education about the Denver Developmental Screening Test when she states: 1. “It screens for gross motor skills.” 2. “It screens for fine motor skills.” 3. “It screens for intelligence level.” 4. “It screens for language development.”

3. The Denver Developmental Test does not test a child’s level of intelligence.

The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the next most appropriate action by the nurse? 1. Give the parents a pamphlet explaining how to install the car seat. 2. Accompany the parents to the car, and show them how to install the car seat. 3. Contact the hospital’s car-seat safety officer, and ask the officer to accompany the parents to the car for car-seat installation. 4. Show the parents a video on car-seat installation and safety, and ask if they are comfortable with the information.

3. The car-seat safety officer is the best choice, as that individual would have the needed information and certification to help the family.

To obtain an adolescent’s health information, the nurse should: 1. Interview the adolescent using direct questions. 2. Gather information during a casual conversation. 3. Interview the adolescent only in the presence of the parents. 4. Gather information only from the parents.

2. Frequently adolescents will share more information when it is gathered during a casual conversation

What can a nurse do to reinforce a 5-year-old’s intellectual initiative when he asks about his upcoming surgery? 1. Answer the child’s questions about his upcoming surgery in simple terms. 2. Provide the child with a book that has vivid illustrations about his surgery. 3. Tell the child he should wait and ask the doctor his questions. 4. Tell the child that she will answer his questions at a later time.

1. The child is taking the initiative to ask questions, as all preschoolers do, and the nurse should always answer those questions as appropriately and accurately as possible.

What information should a school nurse include in a discussion on nutrition with a fourth-grade class? 1. The number of calories that a fourth-grade child should consume in a day. 2. A list of high-calorie foods that all fourth-graders should avoid. 3. How to read food labels so children know which foods are good for them. 4. A list of nutritious foods with basic scientific information about how they affect the body organs and systems.

4. Reviewing nutritious choices keeps the lesson on a positive note, and school-age children are very interested in how food affects their bodies. They are capable of understanding basic medical terminology.

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 is a common cause of injury and death among children of this age. These children often find small objects lying on the floor and place them in their mouths. Older siblings are often responsible for leaving small objects around.

Which action is a developmentally appropriate method for eliciting a 4-year-old’s cooperation in obtaining the blood pressure? 1. Have the child’s parents help put on the blood pressure cuff. 2. Tell the child that if he sits still, the blood pressure machine will go quickly. 3. Ask the child if he feels a squeezing of his arm. 4. Tell the child that measuring the blood pressure will not hurt.

3. Preschool children enjoy games, and it is a good way to elicit their assistance and cooperation during a procedure TIP - The nurse should not promise the child that the procedure will go quickly. The nurse needs to develop a trusting relationship with the child; therefore, only promises that can be kept should be made.

Which activity can the nurse provide for a 9-year-old to encourage a sense of industry? 1. Allow the child to choose what time to take his medication. 2. Provide the child with the homework his teacher has sent. 3. Allow the child to assist with his bath. 4. Allow the child to help with his dressing change.

2. The school-age child is focused on academic performance; therefore, the child can achieve a sense of industry by completing his homework and staying on track with classmates

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.

Many young children believe abuse or illness is their fault, and they should be reminded they are not to blame. Many children this age believe they have acquired a disease or have been abused because they are bad people.

Which comment should the parent of a 2-year-old expect from the toddler about a new baby brother? 1. “When the baby takes a nap, will you play with me?” 2. “Can I play with the baby?” 3. “The baby is so cute. I love him.” 4. “It is time to put him away so we can play.”

4. This is a typical statement that would be made by a toddler. Toddlers are very egocentric and do not consider the needs of the other child.

Which finding would the nurse consider abnormal when performing a physical assessment on a 6-month-old? 1. Posterior fontanel is open. 2. Anterior fontanel is open. 3. Beginning signs of tooth eruption. 4. Able to track and follow objects.

1. The posterior fontanel should close between 6 and 8 weeks of age. -The anterior fontanel usually closes between 12 and 18 months.

Which is the best method of distraction for an 8-year-old who is having surgery later today and is NPO? 1. Use the telephone to call friends. 2. Watch television. 3. Play a board game. 4. Read the central line pamphlet he was given.

A board game is the optimal choice because school-age children enjoy being engaged in an activity with others that will require some skill and challenge.

Which method is the most effective way to present an educational program on abstinence to adolescents? 1. Use peer-led programs that emphasize the consequences of unprotected sexual contact. 2. Teach students methods to resist peer pressure. 3. Offer students the opportunity to care for a simulator infant for 1 week. 4. Offer statistics, pamphlets, and films discussing the consequences of unprotected sexual contact.

1. Adolescents are most concerned with what their peers think and feel. They are most receptive to information that comes from another adolescent.

Which nursing action is most appropriate to gain information about how a child is feeling? 1. Actively attempt to make friends with the child before asking about her feelings. 2. Ask the child’s parents what feelings she has expressed in regard to her diagnosis. 3. Provide the child with some paper to draw a picture of how she is feeling. 4. Ask the child direct questions about how she is feeling.

3. Often children will include much more detail about their feelings in drawings. They will often express things in pictures they are unable to verbalize.

Which reaction would a nurse expect when giving a preschooler immunizations? 1. The child remains silent and still. 2. The child cries and tells the nurse that it hurts. 3. The child tries to stall the nurse. 4. The child remains still while telling the nurse that she is hurting him.

2. The common response of a 5-year-old is to cry and protest during an immunization

Which should the nurse do to prevent separation anxiety in a hospitalized toddler? 1. Assume the parental role when parents are not able to be at the bedside. 2. Encourage the parents to always remain at the bedside. 3. Establish a routine similar to that of the child’s home. 4. Rotate nursing staff so the child becomes comfortable with a variety of nurses.

3. It is very important to try to maintain a child’s home routine both when parents are present and when they have to leave the hospital. This will increase the child’s sense of security and decrease anxiety.

Which should the nurse recommend to the parents of a 9-year-old hospitalized following a bicycle injury? To prevent future injury, their child should: 1. Wear safety equipment while riding bicycles. 2. Read educational material on bicycle safety. 3. Watch a video on bicycle safety. 4. Ride his bike in the presence of adults.

1. Safety equipment is essential for bicycling, skateboarding, and participating in contact sports. Most injuries occur during the school-age years, when children are more active and participate in contact sports.

Which statement accurately describes how the nurse should approach an 11-year-old to do a physical assessment? 1. Ask the child’s parents to remain in the room during the physical exam. 2. Auscultate the heart, lungs, and abdomen first. 3. Explain that the physical exam will not hurt. 4. Explain what the nurse will be doing in basic understandable terms.

4. School-age children are capable of understanding basic functions of the body and can understand what the nurse will be doing if explained in basic terms.

Which statement accurately describes the best method for assessing a 12-month-old? 1. The nurse should assess the child on the examining table. 2. The nurse should assess the child in a head-to-toe sequence. 3. The nurse should have the child’s mother assist in holding her down. 4. The nurse should assess the child while she is in her mother’s lap.

4. Infants are most secure when in proximity to the parent. The parent’s lap is an excellent place to assess the child.

Which statement by an infant’s mother leads the nurse to believe that she needs further education about the nutritional needs of a 6-month-old? 1. “I will continue to breastfeed my son and will give him rice cereal three times a day.” 2. “I will start my son on fruits and gradually introduce vegetables.” 3. “I will start my son on carrots and will introduce one new vegetable every few days.” 4. “I will not give my son any more than 8 ounces of baby juice per day.”

2. Infants should be started on vegetables prior to fruits. The sweetness of fruits may inhibit infants from taking vegetables.

Which statement would indicate to the nurse that a school-age child is not developmentally on track for age? 1. The child is able to follow a four- to five-step command. 2. The child started wetting the bed on admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister.

3. Most school-age children do not have imaginary friends. This is much more common for children of 3 and 4 years of age.

Which stressor is common in hospitalized toddlers? Select all that apply. 1. Social isolation. 2. Interrupted routine. 3. Sleep disturbances. 4. Self-concept disturbances. 5. Fear of being hurt.

2,3,5 2. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt. 3. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt. 5. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt.

Which technique should the nurse suggest to the mother of an 8-year-old who does not want to complete her chores? 1. Grounding. 2. Time-out. 3. Reward system. 4. Spanking.

3. School-age children usually respond very well to a reward system and often enjoy the rewards so much that they will continue chores without continual reminders.

Which toy is the best choice for a 12-month-old? 1. Baby doll. 2. Musical rattle. 3. Board book. 4. Colorful beads.

2. A musical rattle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation.