Question 5451)
An 8-year-old child is terminally ill. Considering the child’s age, which statement
would you most expect the child to make?
A. “After I’m dead, will you come visit me?”
B. “Who will take care of me when I am dead?”
C. “Will it hurt me when I die?”
D. “Can you help me do a videotape about dying from leukemia?”
Answer: C
Explanation: An 8-year-old is concerned about pain and mutilation. An 8-year-old has an understanding that death
is the end of life as we know it and would be unlikely to respond with answers 1 or 2. Answers 1 and 2 are typical
of a preschooler. Answer 4 is typical of an adolescent who wants to leave a legacy.
Question 5452)
A father has bought his 4 month old daughter to the well-baby clinic. Which
statement that he makes is the greatest cause for concern to the nurse?
A. “She cannot sit up by herself.”
B. “She does not hold the rattle as well as she did at first.”
C. “She does not follow objects with her eyes.”
D. “She spits up after a feeding.”
Answer: C
Explanation: A 4-month-old should follow objects with her eyes. A 4-month-old is not likely to be able to sit up by
herself. This behavior is seen at 6 months of age. Not being able to hold the rattle as well as she did at first is
typical of the time after the loss of the grasp reflex and before pincer movement is established. Most newborn
reflexes are gone by about 4 months of age. Spitting up after a feeding is normal 4-month-old behavior.
Question 5453)
A 3-year-old child has all of the following abilities. Which did he acquire most
recently?
A. Walking
B. Throwing a large ball
C. Riding a tricycle
D. Stating his name
Answer: C
Explanation: Riding a tricycle is 3-year-old behavior. Remember, “three years, three wheels.” Children start to
walk at about 1 year of age. Throwing a large ball and stating his name are 2-year-old behaviors. Remember to use
developmental trends when determining the most recently acquired behavior—head to tail and simple to complex.
Look for a complex lower body behavior.
Question 5454)
The mother of a 2-year-old child calls the doctor’s office because her child
swallowed “the rest of the bottle of adult aspirin” about a half hour ago. The nurse determines
that there were about 15 tablets left in the bottle. What initial assessment findings are consistent
with aspirin ingestion?
A. Bradypnea and pallor
B. Hyperventilation and hyperpyrexia
C. Subnormal temperature and bleeding
D. Melena and bradycardia
Answer: B
Explanation: The child will have an elevated body temperature. Contrary to what you might expect, metabolism is
increased following aspirin overdose. The child will be hot and flushed. Hyperpyrexia means high temperature. The
child will be in metabolic acidosis from the acid load of the aspirin. Compensation for metabolic acidosis is rapid,
deep breathing. The first choice is incorrect; the child will be hyperventilating and will be flushed, not pale. The
third choice is not correct; the temperature will be high, not low. Bleeding may occur following aspirin ingestion,
but not initially. The fourth choice is not correct. Melena is hidden blood in the stool. It will take some time for a
gastrointestinal bleed to develop and pass through the stool. Bradycardia will not be present. The child will have
tachycardia.
Question 5455)
A toddler who has swallowed several adult aspirin is admitted to the emergency
room. When admitted, the child is breathing but is difficult to arouse. What is the immediate
priority of care?
A. Administration of syrup of ipecac
B. Cardiopulmonary resuscitation
C. Ventilatory support
D. Gastric lavage
Answer: D
Explanation: Since the child is breathing, there is no need for cardiopulmonary resuscitation (CPR) or ventilatory
support. Gastric lavage is usually used rather than inducing emesis. In any event, the child is difficult to arouse, so
it would not be safe to induce vomiting.
Question 5456)
A 6-month-old child is being seen for a well-baby visit. The child has received all
immunizations as recommended so far. What immunizations does the nurse expect to give at this
visit?
A. DTP, MMR, IPV
B. DTP, hepatitis B, HIB
C. HIB, IPV, varicella
D. MMR, hepatitis B, HIB
Answer: B
Explanation: At 6 months of age, the nurse would expect to administer the third DTP, the third hepatitis B, and the
third Haemophilus influenzae type B (HIB) immunizations. MMR (measles, mumps, and rubella) is not given until 15
months of age. IPV is given at 2 months and 4 months and then again at 18 months and preschool. Varicella vaccine
is given between the ages of 1 year and 12 years.
Question 5457)
The mother of a 6-year-old child who has chickenpox asks the nurse when the
child can go back to school. What information should be included in the nurse’s response? The
child is contagious:
A. until all signs of the disease are gone
B. as long as the child has scabs
C. as long as there are fluid-filled vesicles.
D. until the rash and fever are gone.
Answer: C
Explanation: Chickenpox is contagious as long as there are fluid-filled vesicles. Scabs are not contagious. The child
will have scabs for a while. The fever may be down, but if there are fluid-filled vesicles, the child is contagious.
Question 5458)
A 2-year-old child is in for an annual examination. Which comment by the mother
alerts the nurse to a risk for lead poisoning?
A. “Why does he eat paint off the window sills?”
B. “Will his temper tantrums ever stop?”
C. “I haven’t been able to toilet train him yet.”
D. “He is such a messy eater.”
Answer: A
Explanation: Eating paint is one of the major risk factors for lead poisoning. Temper tantrums are normal in a 2-
year-old. Most 2-year-olds are not toilet trained. Most 2-year-olds are messy eaters.
Question 5459)
A 6-year-old boy has tetralogy of Fallot. He is being admitted for surgery. The
nurse knows that which problem is not associated with tetralogy of Fallot?
A. Severe atrial septal defect
B. Pulmonary stenosis
C. Right ventricular hypertrophy
D. Overriding aorta
Answer: A
Explanation: Atrial septal defect is not associated with tetralogy of Fallot. The four defects are pulmonary stenosis,
which causes right ventricular hypertrophy, ventricular septal defect, and overriding aorta.
Question 5460)
A 6-year-old child with tetralogy of Fallot is being admitted for surgery. While the
nurse is orienting the child to the unit, the child suddenly squats with the arms thrown over the
knees and knees drawn up to the chest. What is the best immediate nursing action?
A. Observe and assist if needed
B. Place the child in a lying position
C. Call for help and return the child to the room
D. Assist the child to a standing position
Answer: A
Explanation: The squatting position will help the child with tetralogy of Fallot to have better hemodynamics. It
increases intra-abdominal pressure and increases pulmonary blood flow. Placing the child in a lying or standing
position will increase his symptoms and be counterproductive. It is not necessary to call for help because this is not
an emergency situation.
No comments:
Post a Comment