St. Louis Review Center 7.
A friend is shopping for a toy to give to her
2ND FLOOR CAP BLDG, J. ROSALES AVENUE, CORNER J.C.
AQUINO AVENUE, BUTUAN CITY
TELEPHONE NUMBER (085) 342-2339
PEDIATRIC NURSING
1. The nurse discusses dental care with the parents
of a 3-year old. The nurse explains that by the age
of 3, their child should have:
a. 5 "temporary" teeth c. 15 "temporary"
teeth
b. 10 "temporary" teeth d. 20 "temporary"
teeth
2. The mother of a 6-month old infant is concerned
that the infant's anterior fontanel is still open.
The nurse would inform the mother that further
evaluation is needed if the anterior fontanel is
still open after:
a. 6 months c. 18 months
b. 10 months d. 24 months
3. The nurse has discussed appropriate support of
the young infant to prevent injuries from falls.
The mother who needs further education is the
mother who states:
a. "My child is not allowed to have his walker
near the stairs."
b. "I never leave my baby unattended on my
bed."
c. "By the time my infant is 6 months old, hw
will be able to sit without support."
d. "Before my child is standing, I need to place
the crib mattress at its lowest level.
4. The 9-year-old child is at the 98th percentile for
weight and at the 40th percentile for height. The
school nurse will interpret that this child is:
a. Underweight or small in stature
b. Overweight or large in stature
c. Experiencing a prepubescent growth spurt
d. Normal for size
5. In discussing sexual maturation with a health
class, the nurse would include the information
that secondary sex characteristics begin to appear
at:
a. 10 years in girl, 12 years in boys
b. 12 years in girls, 16 years in boys
c. 8 years in boys, 10 years in girls
d. 12 years in girls and boys
6. A recently hospitalized 2-year-old client screams
and shouts that he wants a "bottle." His parents
are puzzled, and state that he has drank from a
cup for the past year. The nurse explains that:
a. Irritability is exhibited in all age group
b. Temper tantrums often represent the child's
need for parental attention
c. Various forms of punishment are necessary
when such behaviors occur
d. Regression to an earlier behavior often helps
the child cope with stress and anxiety
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
nephew. The friend knows nothing about children
and asks what would be the most appropriate toy
to give an 18-month-old child. Based on growth
and development skills, the nurse recommends a:
a. Tricycle c. Pull toy
b. Large ball d. Stuffed animal
8. The nurse is preparing an 8-year old child for a
procedure. What is the most appropriate nursing
intervention?
a. Provide visual aids, such as dolls, puppets,
and diagrams in the explanation
b. Provide a written pamphlet for the child to
review prior to the procedure
c. Discourage any display of emotional
outbursts
d. Request that parents wait outside while the
nurse provides instructions to the child
9. The nurse explains that the Pediatrics formula are
continued in a child's dietary intake up until what
age?
a. 6 months c. 18 months
b. 12 months d. 24 months
10. Piaget identifies that the 2 to 7 year old chi8ld is
in a preoperational stage. The nurse observes a
toddler taking a toy from another. The nurse
recognizes the child unable to put him or herself
in the place of another is displaying:
a. Centration c. Egocentrism
b. Negativism d. Selfishness
11. A 7-month old infant has all of the following
abilities. Which skill was most recently acquired?
a. Smiling at self in a mirror
b. Transferring a rattle from one hand to the
other
c. Rolling from back to abdomen
d. Imitating sounds
12. The school health nurse is doing vision testing.
visual acuity is assessed using:
a. The Snellen eye chart c. The cover-uncover
test
b. An ophthalmoscope d. The Weber test
13. Children are usually brought to the clinic for
health care by a parent. At what age is it
appropriate for the nurse to question the child
about presenting symptoms?
a. 3 years b. 5 years c. 7 years d. 9 years
14. When recording the health history of a child,
what information that is uniquely pertinent to
children is important for the nurse to obtain?
a. Past hospitalizations c. immunization status
b. Coping strategies d. Past accidents
15. A mother overhears a nurse state that the nurse
is going to complete a genogram and asks the
nurse what that means. The nurse's reply would
be based on knowledge that a genogram is useful
for visually showing what information?
a. Treatment protocols
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 b. Family history Past history
c. Immunization status
16. When plotting a child's height and weight on a
growth grid, the nurse understands that which
range represents the normal percentile range for
children?
a. 10th to 90th percentile
b. 25th to 75th percentile
c. 50th to 100th percentile
d. 5th to 95th percentile
17. When assessing a child who complains of
abdominal pain, what is the most appropriate
nursing action?
a. Palpate the most painful area first
b. Palpate for rebound tenderness
c. Avoid painful areas until the end of the
assessment
d. Use deep palpation for abdominal tenderness
18. When sharing the purpose of the Denver
Development Screening Test (Denver II) with
parents of an 18-month old, the nurse should
explain that:
a. The Denver II is a test that will predict future
intellectual ability
b. The Denver II is a screening test used to
detect children who may be slow in
development
c. The Denver II is used for early detection of
speech disorders
d. The Denver II measures psychological,
cognitive, and social development
19. What should the nurse do first when preparing to
do a physical assessment on a sleeping 8-month-
old baby?
a. Measure the occipital-frontal head
circumference
b. Auscultate the heart and lungs
c. Check the eyes for the red reflex
d. Wake the baby
20. When preparing to examine a preschool child, the
nurse should:
a. Give detailed explanations to alleviate the
child's anxiety
b. Give reassurance and feedback to the child
during the examination
c. Suggest that the child act like "the big kids"
when he or she is examined
d. Say that the shirt is the only clothing that
must be removed
21. The physician orders amoxicillin (Amoxil) 500mg
IVPB q 8 hours for a pediatric client with
tonsillitis. What is the appropriate nursing action?
a. Question the order because the route of
administration is incorrect
b. Give the medication as ordered
c. Question the order because the dosage is too
high
d. Question the order because the dosing
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
frequency is incorrect
22. The nurse administers cefprozil (Cefzil) as ordered
to a 22-month-old client with bacterial
pharyngitis. The nurse notes patches of white on
the child's oral mucosa that cannot be removed.
Which condition does the nurse suspect?
a. Allergic reaction to the medication
manifested by the development of stomatitis
b. A herpes simplex virus infection
c. Oral thrush caused by Candida albicans
d. Mumps
23. A pediatric client has been diagnosed with otitis
media. The nurse should place highest priority on
teaching the parent:
a. How to administer eardrop
b. The importance of completing the full course
of antibiotic therapy
c. About myringotomy and tympanostomy tube
insertion
d. About eliminating environmental allergens
24. Nursing care of the child who is postoperative for
a tonsillectomy should include:
a. Applying warm, moist compresses to the neck
area
b. Observing for excessive swallowing
c. Maintaining the child in a supine position
d. Offering warm liquids with a straw for the
child to sip
25. The nurse is caring for a child with a common cold
(nasapharyngitis). The primary goal of nursing
care is directed toward:
a. Preventing injury
b. Promoting nutrition
c. Relieving symptoms
d. Administering antibiotics
26. The nurse obtains a health history on a pediatric
client. A sign alerting the nurse to possible
hearing impairment in the child is:
a. Distractibility and short attention span
b. Disinterest in reading storybooks
c. Turning up the volume on the family
television set
d. Temper tantrums
27. The nurse is caring for a 1-month old client who is
blind, secondary to retinopathy or prematurity.
The nurse is teaching the parents about activities
to promote their infant's development. Which of
the following statements by the nurse is correct?
a. "Infants with visual impairment respond to
tactile stimuli rather than auditory stimuli."
b. "Talking, holding, and singing to your baby
are appropriate activities at this age."
c. "You should expect your baby to smile in
response to your voice by 4 months of age."
d. "Position the baby side-lying in the crib at all
times, and avoid loud noises that could startle
the infant."
28. The nurse is assessing a child with conjunctivitis
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 (pink eye). Which of the following would the
nurse most likely assess?
a. Serous drainage from the affected eye
b. Severe eye pain
c. Periorbital edema
d. Crusting of eyelids and eyelashes
29. The nurse teaches a child with conjunctivitis
measures to prevent the spread of infection. The
nurse recognizes that further teaching is needed
when the child states the following:
a. "I will wash my hands frequently."
b. "I will use a tissue to clean my eye and then
throw the tissue away."
c. "I will use my own washcloth and towel, and
not use my brother's."
d. "I will carry a handkerchief with me so that I
can wipe my eyes during the day."
30. A 4-month old infant has severe nasal congestion,
nasal mucous drainage and crusting in and
around the nares. What is the best way for the
nurse to clear the infant's nasal passage?
a. Administer vasoconstrictive nose drops every
3 hours
b. Place the infant in a mist tent
c. Administer saline drops in the nose and
suction with bulb syringe
d. Instruct the client to blow the nose and keep
disposable tissues handy
31. The mother of an infant who has had recurrent
respiratory infections asks the nurse why infants
are at increased risk for complications from
respiratory infections. The best response by the
nurse explains that in infants, the:
a. Airway structures are larger, allowing for
larger numbers of organisms
b. Respiratory rate is slower than in adults
c. Parents are unable to accurately assess
respiratory problems
d. Airways are narrower and more easily
obstructed
32. The mother of a neonate hospitalized with upper
respiratory tract infections asks why her baby
won't take her bottle. The nurse's best answer
would be:
a. "She's probably not hungry."
b. "It's okay because we're giving her
intravenous fluids, therefore she is not
hungry."
c. "Newborns breathe through their noses.
Congestion may be interfering with her
breathing and eating at the same time."
d. "She might need a different type of formula.
We'll call the physician to get a new order."
33. A 4-year old female child presents to the
emergency department with a sore throat,
difficulty swallowing and a suspected diagnosis of
acute epiglottitis. Which of the following should
not be included in her initial assessment?
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
a. Throat culture c. Past medical history
b. Vital signs d. Auscultation of chest
34. The nurse is providing home care instructions to
the parents of a child with cystic fibrosis. Which
statement by the parents indicated that they do
not understand the treatment regimen?
a. "We will perform chest physiotherapy and
postural drainage four times a day."
b. "We will keep her away from the church
nursery if any of the children are coughing
and have fever or runny noses."
c. "If her bowel movements are normal and her
appetite is good, she does not need her
pancreatic enzymes."
d. "The relay races and swimming at our Sunday
school picnic next week will be good exercise
for her."
35. A 2-year-old child is being discharged after
bronchoscopy for removal of a coin from his
esophagus. The most important topic of
discharge teaching would be the importance of:
a. Reassuring the child that he is fine
b. Proper nutrition for the next few days
c. Restricting his access to small toys or objects
d. Administering acetaminophen for his sore
throat
36. A 15-year-old child with a history of cystic fibrosis
is admitted to the pediatric unit with assessment
findings of crackles, increased cough, and
greenish sputum. A 2-week hospitalization is
anticipated. Which nursing intervention holds the
highest priority?
a. Referral to Child Life Services for school
lesson plans
b. Arranging for liberal visitation from peers
c. Taking a diet history
d. Gaining intravenous access
37. A 7-year-old child is brought to the Emergency
Department for an acute asthma attack. He is
wheezing, tachypneic, diaphoretic, and looks
frightened. The nurse should prepare to
administer:
a. IV methylprednisolone
b. Racemic epinephrine
c. Oral prednisone
d. Cromolyn sodium
38. An appropriate nursing diagnosis for the family of
a toddler being treated for acute
laryngotracheobronchitis to:
a. Anticipatory grieving
b. Altered growth and development related to
acute onset of illness
c. Impaired social interaction related to
confinement in hospital
d. Fear/anxiety related to dyspnea and noisy
breathing
39. A child with bacterial pneumonia is crying and
says it hurts when he coughs. The nurse would
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 teach the child to:
a. Hug his teddy bear when he coughs
b. Ask for pain medicine before he coughs
c. Take a sip of water before coughing
d. Try very hard not to cough
40. An infant with chronic bronchopulmonary
dysplasia (BPD) and a tracheostomy is being
discharged on home oxygen therapy. Which
statement by the mother indicates that further
teaching is needed before discharge?
a. "I will call my pediatrician if she gets a fever
or has more secretions than usual from her
tracheostomy."
b. "I have a cute bib to loosely cover her
tracheostomy when she eats and when we go
outside in the wind."
c. "We are so glad the baby will get to go with
us on our camping trip to Yellowstone
National Park. We have been waiting for her
to get well so we can go."
d. "We have already notified Alabama Power
Company that our baby is coming home today
41. An infant is admitted with an acyanotic heart
defect. Which assessment finding should be
discussed with the physician?
a. Heart murmur c. Weight gain
b. Dyspnea d. Eupnea
42. For an infant client with a cyanotic heart defect,
which symptoms would indicate risk for
congestive heart failure?
a. Respiratory crackles and frothy secretion
b. Decreased cyanosis
c. Increased blood pressure
d. Oxygen saturation increase
43. A child is admitted with a diagnosis of "rule out
rheumatic fever". Which assessment finding
supports this diagnosis?
a. Elevated antistreptolysin-O (ASO)
b. Elevated hematocrit
c. Decreased hemoglobin
d. Decreased salicylate level
44. A child is admitted with possible coarctation of
the aorta. Which of the following orders should
be questioned?
a. Regular diet
b. BP of upper and lower extremities q 4 hours
c. Intake and output
d. Vital signs on admission, then Q.D.
45. A child with tetralogy of Fallot becomes acutely ill
with an increase in cyanosis, tachycardia, and
tachypnea. Which nursing action would be most
effective to relieve cardiac load?
a. Place child in Trendelenburg position
b. Place child in knee-chest position
c. Have oxygen equipment available
d. Maintain suction equipment available
46. A child with a cyanotic heart defect is being
discharged home to await surgical repair. In the
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
discharge teaching, the nurse instructs the
parents:
a. To prevent the child from crying at all
b. To observe the child for signs of increased
intracranial pressure
c. In cardio-pulmonary resuscitation
d. To identify growth and development
milestones
47. A client with rheumatic fever is admitted to the
nursing unit. The nurse's most important
intervention is to:
a. Prevent spread of rheumatic fever
b. Provide comfort from arthralgia
c. Evaluate for nervous system complications
d. Teach parents about cardiopulmonary
resuscitation (CPR)
48. A child with Kawasaki's disease is admitted to the
pediatric unit. Since promotion of comfort is an
appropriate nursing goal, the nurse:
a. Administers aspirin and immunoglobulins as
ordered
b. Administers Tylenol and immunoglobulins as
ordered
c. Keeps child NPO for the first 24 hours
d. Encourages a vigorous exercise program
49. A pediatric client is discharged after an acute
phase of rheumatic fever. The priority discharge
instruction given by the nurse is that the child:
a. Is to resume regular activities
b. Needs to take antibiotics as ordered
c. Needs to maintain complete bed rest
d. Will experience central nervous system (CNS)
complications
50. A pediatric client with a cyanotic heart defect
experiences a cyanotic episode. Symptoms
consistent with this cyanotic episode would
include:
a. Skin is ruddy or mottled prior to cyanosis
b. Decreased rate of respirations
c. Decreased heart rate
d. Lethargy
51. A child has been admitted with a history of a
seizure 2 hours ago. The history reports fever,
chills, and vomiting for the past 24 hours. In
report, the nurse is told that the child has a
positive Brudzinski's sign. The nurse knows that
this is most likely caused by:
a. Increased intracranial pressure
b. Meningeal irritation
c. Encephalitis
d. Intraventricular hemorrhage
52. A nurse is assessing a new admission. The 6-
month-old infant displays irritability, bulging
fontanels, and setting-sun eyes. The nurse would
suspect:
a. Increased intracranial pressure
b. Hypertension
c. Skull fracture
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 d. Myelomeningocele
53. An 8-year-old client with a ventriculoperitoneal
shunt was admitted for shunt malfunction. He
presents with symptoms of increased intracranial
pressure. The mechanism of the development of
his symptoms is most probably related to:
a. Increased flow of cerebrospinal fluid
b. Increased reabsorption of cerebrospinal fluid
c. Obstructed flow of cerebrospinal fluid
d. Decreased production of cerebrospinal fluid
54. A child with a myelomeningocele is started on a
bowel management plan. the child's mother
questions why this is being done. The nurse's
response will be based on the understanding
that:
a. Lack of innervations to the colon predisposes
the child to diarrhea
b. Lack of innervations to the anal sphincter
predisposes the child to being incontinent
c. Lack of mobility increases the gastric-colic
reflex
d. Lack of mobility decreases the need for
regular bowel movements
55. A child has just been diagnosed with bacterial
meningitis. The parent asks the nurse how long
the child will be in isolation. The nurse's reply will
be based on a protocol that isolation continues
until:
a. The organism is located
b. The antibiotics are initiated
c. The antibiotics have been administered for 24
hours
d. Ten days of antibiotic therapy have been
completed
56. The nurse observes a client with the neck and
back arched and extremities severely extended.
The mother asks why the child is doing that. The
nurse explains that this posturing is called:
a. Decerebrate c. Jacksonian seizure
b. Decorticate d. Opisthotonos
57. A child is being treated for increased intracranial
pressure (ICP). Which intervention would be
contraindicated to order to decrease ICP?
a. Keeping head of bed at a 30-degree angle
b. Providing supplemental oxygen
c. Turning head to one side
d. Administering IV osmotic diuretics as ordered
58. A 10-year-old boy receives a blow to his head
with a hard baseball and is admitted to the
hospital for observation. If the child were to
develop an epidural hematoma, the child would
most like display symptoms
a. In the emergency room or soon after arriving
on the unit
b. On the unit over the next few days
c. After discharge home
d. Over the next two months
59. A 15-year-old client is seen in the emergency
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
department following a head injury from football.
During the first few hours after admission, he
sleeps unless awakened, but he can be aroused
easily and is oriented. In charting assessment
findings, the nurse would describe this level of
consciousness as:
a. Semicomatose c. Obtunded
b. Lethargy d. Stuporous
60. A young child has just been diagnosed with
cerebral palsy. The nurse is teaching the parents
how to meet the dietary needs of their child. The
nurse would explain that children with cerebral
palsy frequently have special dietary needs or
feeding challenges because:
a. The paralysis of their muscles decreases their
caloric need
b. The spasticity of muscles increases their
caloric need
c. All children with cerebral palsy require
assistance with feedings
d. The child's inactivity increases the risk of
obesity
61. A newborn is found to have exstrophy of the
bladder. The nurse should evaluate the infant for:
a. Hypospadias c. Cryptorchidism
b. Epispadias d. Acute tubular necrosis
62. A child has been admitted to the hospital with a
diagnosis or “rule out nephrosis.” The nurse
would assess the child for:
a. Hematuria c. Petechial rash
b. Edema d. Dehydration
63. The nurse is caring for a toddler who is not toilet-
trained. The doctor has ordered intake and
output measurement. The nurse will most
accurately measure the urine by:
a. Estimating output as small, moderate, or
large and recording on the child’s chart.
b. Weighing each wet diaper and recording the
amount of urine output as the weight of the
diaper.
c. Subtract the weight of a dry diaper from a
wet diaper and record this amount.
d. Determine urine output by the number of
diaper changes in each 24-hour period.
64. The nurse is teaching the parents of preschooler
information about urinary tract infection and
means of reducing their recurrence. Which
statement by the parents indicated the need for
additional teaching?
a. “I should try to get her to drink a lot of water
and juices.”
b. “I will buy her underwear a little large.”
c. “Soaking in a bubble bath will reduce meatal
irritation.”
d. “If I notice her starting to wet the bed again, I
need to have her checked for another urinary
tract infection.”
65. The nurse would include which of the following in
5
 the care of a child with acute glomerulonephritis?
a. Careful handling of edematous extremities
b. Observing the child for evidence of
hypotension
c. Providing fun activities for the child on bed
rest
d. Feeding the child a protein-restricted diet
66. A urinalysis is ordered for a child with a throat
culture positive for group-A beta-hemolytic
streptococcus (strep throat). The mother asks
why this test is being ordered. The nurse Explains:
a. The urinalysis will indicate whether an HIV
infection is also present.
b. Urinary tract infections are common with
streptococcal infections and need to receive
prompt treatment.
c. Pyelonephritis is a potential complication of
antibiotic therapy.
d. Group-A beta-hemolytic streptococcus
infections can be followed by the
complication of acute glomerulonephritis.
67. An appropriate nursing diagnosis for a toddler
with unrepaired exstrophy of the bladder would
be:
a. Disorganized infant behavior c. Urinary
retention
b. Sexual dysfunction d. Risk for infection
68. A child has been admitted to the unit with acute
glomerulonephritis. The test that would confirm
this diagnosis is:
a. Antistreptolysis-O (ASO) titer
b. Urinalysis
c. Blood cultures d. White blood cell (WBC)
count
69. The doctor orders a clean-catch urine specimen
on an infant who is not toilet-trained. The best
means of collecting this urine would be to:
a. Perform a straight catheterization
b. Apply a urine collection bag
c. Use diaper analysis
d. Perform Foley catheterization
70. A teenage child is being treated for renal failure.
The nurse would ensure that the child follows a:
a. High-sodium diet c. Low-sodium diet
b. High-protein diet d. Low-fiber diet
71. A mother tells the nurse that her child has been
diagnosed with hypertrophy of the thyroid gland.
The mother states the doctor called it something
else and asks the nurse what the other name for
this is. The nurse’s reply should be:
a. Glandular enlargement c. Lymphadenopathy
b. Goiter d. Thyrotoxicosis
72. An infant was born 24 hours ago. The nurse has
been instructed to collect blood by heel stick for
neonatal screening for congenital hypothyroidism
before the baby is discharged. The nurse
discusses options with the pediatrician knowing
that 24 to 48 hours after birth is not the optimal
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
time to collect this specimen because:
a. At 24 hours, the T4 level will be extremely low
b. There is an immediate rise in the TSH after
birth
c. The baby needs to digest formula before a
blood sample can be taken
d. A thyroid scan should be done first
73. The nurse is administering propylthiouracil to a
12-year old female recently diagnosed with
Graves’ disease. The child has been receiving the
drug 3 times a day for 3 weeks. She suddenly
complains of severe soar throat. What would be
the appropriate nursing action?
a. Continue to give the medication or she will
continue to exhibit signs of Grave’s disease
b. Offer lozenges for the relief of the sore throat
c. Hold that dose and report the complaint to
the physician since a sore throat is a common
side effect
d. Assume that she is complaining in order to
avoid going to the school room in the hospital
74. A 10-year old diabetic client told the nurse that
he had some early signs of hypoglycemia while
attending school. What would be the best action
for the child to take?
a. Take an extra shot of regular insulin
b. Drink a glass of orange juice
c. Skip the next dose of insulin
d. Start exercising
75. The nurse is teaching an adolescent client about
the different types of insulin. The client takes
NPH insulin at 8:00 A.M. The nurse would instruct
the client that he could possibly expect an insulin
reaction at what time of the day?
a. While working out at 9:00 A.M.
b. While taking a test at 10:00 A.M.
c. While eating lunch at noon
d. While golfing after school at 3:00 P.M.
76. A teenage mother arrives at the clinic with her
new baby who has recently been diagnosed with
congenital hypothyroidism. When instructing the
mother about administering levothyroxine
medication, the nurse would include the
information that she should:
a. Crush the medication and place in a full bottle
of formula or juice to disguise the taste
b. Administer the medication every third day
c. Give the crushed medication in a syringe or in
the nipple mixed with a small amount of
formula
d. Understand that the medication will not be
needed after age 5
77. A new mother of an infant diagnosed with
phenylketonuria (PKU) meets with the nurse who
informs her that PKU follows autosomal recessive
inheritance. The mother states that is a relief
since she now knows her next baby will not have
the disease. What additional information does
6
 the mother need?
a. With autosomal recessive inheritance, each
baby has a 25 percent chance of having the
disease
b. Only female babies will have PKU
c. The mother passes the gene only to male
offspring
d. Since she already has one baby with the
disease, the next one will probably be a
carrier for the disease
78. A 4-month old infant has been diagnosed with
PKU. The child has eczema and sensitivity to the
sunlight. The mother asks the nurse why her
child’s skin is so sensitive. An appropriate
explanation by the nurse would be:
a. “Some children just have sensitive skin.”
b. “Your child will outgrow his sensitivity when
he is 5 years old. Just use sunscreen for now.”
c. “Your child has a deficiency in melanin
because of decreased tyrosine. You will
always have to take special care of his skin.”
d. “The phenylketones in your baby’s blood
concentrate the sun’s rays, making burning
more likely. Children with PKU can never be in
the sun.
79. The nurse was working with a group of parents of
children with phenylketonuria. The nurse has
completed family teaching on the dietary
restrictions. The parents are given sample menus
to choose a meal for their child. Which menu
choice indicates understanding of the dietary
instructions?
a. A hamburger and a diet soda sweetened with
aspartame
b. Steak and mashed potatoes with orange juice
c. A large bowl of cereal with strawberries and
apple juice
d. Milkshakes and grilled cheese sandwich
80. Mothers in the waiting room of the endocrine
clinic are discussing their children’s illnesses. The
mothers of children with phenylketonuria and
congenital hypothyroidism recognize there is a
common goal in the early treatment of their
children. That goal is the avoidance of:
a. Mental retardation c. Obesity
b. Fever d. Protein foods
81. A 6-year-old child has a cast applied for a
fractured radius. The nurse completes an
orthopedic assessment on this child. Which of the
following symptoms requires immediate
attention and should be reported to the
physician?
a. Capillary refill of 4 seconds in the affected
hand
b. Edema in the affected fingers that improves
with elevation
c. Child describing feeling of the affected hand
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being asleep
d. Skin surrounding the cast is warm
82. Which of the following nursing care measures
takes highest priority in caring for a child in
skeletal traction?
a. Assessing bowel sounds every shift
b. Assessing temperature every 4 hours
c. Providing adequate nutrition
d. Providing age-appropriate activities
83. A nurse performs a triage in a pediatric
orthopedic clinic. Which of the following should
the nurse recognize as a symptom of slipped
capitol femoral epiphysis?
a. Pain in the hip of a preadolescent child
b. Acute onset of knee pain
c. Presence of a limp in a school aged child
d. Painful external rotation of the affected leg
84. Which of the following statements made by the
parent of a child being discharged with
osteomyelitis requires further teaching by the
nurse?
a. “I can stop the antibiotics when I see that my
child is feeling better.”
b. “We will make sure that our child has plenty
of calcium and protein.”
c. “I will look at the intravenous site for signs of
infection a couple of times a day.”
d. “My child won’t take physical education at
school until allowed by the doctor.”
85. A 5-month-old infant is being assessed for
develop0mental dysplasia of the hip. The nurse
will look for a positive:
a. Ortolani sign c. Allis sign
b. Barlow sign d. Trendelenburg sign
86. A newborn is being admitted to the newborn
nursery. The nurse would assess the infant for
congenital defects. In addition to the abnormal
position of the foot, the nurse would note which
of the following if clubfoot were present?
a. Affected foot is larger and longer
b. Affected limb is longer
c. There is calf muscle atrophy of the affected
limb
d. Affected foot is cooler
87. A child is admitted with osteogenesis imperfecta
(OI). In reviewing laboratory findings, the nurse
would expect to find abnormal levels of:
a. Calcium c. Precollagen type I
b. Phosphorus d. Vitamin D
88. Which of the following statements made by a
parent of a child with OI needs clarification by the
nurse?
a. “My child may be able to participate in
sports.”
b. “There are no medications available to help
this disease process.”
c. “Surgery may be needed to place rods in the
bone for stability.”
7
 d. “My child will need to be home schooled to a. Continuing oral antibiotics until the
protect him from injury.” prescription is completed
89. Which of the following interventions is b. Strict bed rest with the left leg elevated
inappropriate to incorporate into the plan of care c. Increased fluid intake
for a child with Duchenne muscular dystrophy d. Limiting visitors to prevent spreading
hospitalized for a respiratory infection? infection
a. Physical therapy 99. When teaching a mother how to use an anti-lice
b. Vigorous antibiotic therapy shampoo, the nurse should include the
c. Passive range of motion exercises information that she should:
d. Strict bed rest a. Use ample shampoo to cover the hair
90. A 14-year-old adolescent has just been fitted for a b. Apply about 2 ounces of shampoo to wet hair
Milwaukee brace. Which of the following should c. Leaver the shampoo on hair for 20 to 30
the nurse include in teaching about this brace? minutes before rinsing
a. The brace should be worn only when the d. Use hot water for both shampoo and rinse
adolescent is sleeping or in the recumbent 100. The nurse would share which of the following
position pieces of information to increase treatment
b. The brace should be worn next to the skin compliance in a teenager with eczema?
c. Exercises to increase pelvic tilt should be a. The appearance of the skin will improve in a
done several times per day while in the brace few days
d. The adolescent should experience no pain as b. Avoiding foods with eggs and milk will speed
a result of wearing this brace healing
91. When bathing a 3-year-old with eczema, the c. Scarring is not likely if the treatment plan is
nurse tells the mother to have the bathwater: followed
a. As hot as the child can tolerate d. This problem will not likely recur past
b. Hot to the touch on the inner wrist adolescence
c. Tepid d. Cool
92. The nurse explains to the mother that a child who
has begun treatment for impetigo with a topical
“There is no limit to the good a person can do if
antibiotic can return to daycare:
he is willing to let someone else take the credit.”
a. Immediately c. As soon as crust are evident
b. After 48 hours d. When crusts fall off
93. When assessing a child’s hair and scalp, the nurse
notices what looks like dandruff but it does not
flake off easily. The nurse suspects the child has:
a. Scabies c. Pediculosis capitus
b. Eczema d. Impetigo
94. The nurse plans to position a child with a
circumferential burn of the right leg”
a. Flat in bed
b. With the right leg dependent
c. On the left side
d. With the right leg elevated
95. A 3-year-old child has been diagnosed with
eczema. The nurse will assess for:
a. Pruritus c. Vesicles
b. Pustules d. Lichenification
96. A child has been diagnosed with eczema. While
taking the nursing history, the nurse will assess
for a family history of:
a. Scabies b. Cellulitis c. Asthma d. Impetigo
97. When assessing a child with Periorbital cellulites,
the nurse will want to ask the parent about a
recent history of:
a. Otitis media c. Dog bite
b. Sinusitis d. Sun exposure
98. A child will be treated at home for cellulites of the
left leg. The nurse will include in client education
the need for:

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(Answer: C) A teenager can and should be part of the
treatment plan. If itching is avoided to prevent
excoriation and secondary infection, scarring is unlikely.
Improvement is often slow, and the problem may persist
into adulthood. Food avoidance will not change the
course of the disease.
101. A 14-year-old child is receiving intravenous
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antibiotics for an infection. The physician has ordered
gentamycin (Garamycin). Because of the side effects of
this drug, the nurse would monitor:
a. Temperature
b. Blood pressure
c. Intake and output
d. Breath sounds
(Answer: C) Rationale: One of the most common side
effects of gentamycin is nephrotoxicity. The nurse can
monitor kidney function by monitoring intake and output.
102. A 3-year-old child is admitted to the hospital to rule
out an infection. Which diagnostic test is likely to
differentiate an infection from an allergic response?
a. Hemoglobin and hematocrit
b. Red blood cell count
c. White blood cell count differential
d. Platelet agglutinization
(Answer: C) Rationale: White blood cells are one
component of the general nonspecific immune response.
They among the first responders stimulated by a
pathogenic organism. A white blood cell differential can
often determine if the illness is of bacterial, viral, or
allergic origin.
103. A 2-year-old child has eczema that causes extreme
itching. Treatment has not been able to control the rash.
It has been determined that the primary allergen is
wheat. An appropriate nursing diagnosis for this child
would be:
a. Risk for infection
b. Altered nutrition, more than body requirements
c. Ineffective infant feeding behavior
d. Noncompliance
(Answer: A) Rationale: Because of the itching, the child
will be scratching. Intense scratching can break the skin,
and the child might develop a bacterial infection
secondary to the skin trauma. Altered nutrition, more
than body requirements, does not clearly state the
problem with the food allergies, nor does ineffective
infant feeding behavior. There is no evidence of
noncompliance.
104. A child’s mother tells the nurse that her child has
been on steroids for several months. Which of the
following vaccines is contraindicated?
a. Tetanus toxoid
b. Measles, mumps, and rubella (MMR) made from
egg embryo
c. Poliovirus vaccine inactivated
d. Poliovirus vaccine live oral trivalent
(Answer: D) Rationale: Oral poliovirus vaccine contains
a live virus, which could cause an infection in a child who
is immune-depressed as a result of taking steroids.
105. A child with severe combined immunodeficiency
disorder (SCID) is being discharged from the hospital to
home. The nursing care goal for the client before and
after discharge would be that the child:
a. Remains well oxygenated
b. Remains free of infection
c. Maintains hydration
d. Avoids contact with other people
(Answer: B) Rationale: Care of the immunocompromised
child focuses on preventing infection. The nursing
interventions related to reaching this goal might include
limiting contact with a large number of people, but that
would not be the goal of the nursing care plan.
106. A child is being worked up for allergies. The mother
asks how the diagnosis will be made. The nurse’s
9
response is based on the knowledge that allergies can
be diagnosed based on:
a. Medical history of urticaria alone
b. IgG levels
c. Decreased eosinophil count
d. RAST test
(Answer: D) Rationale: Allergies are confirmed by RAST
test. RAST is a radioallergosorbent test that detects IgE
antibodies that are part of the allergic response. Urticaria
is itching and is symptomatic of allergies and other
diseases, and an increase in eosinophils is diagnostic of
allergies.
107. A child is born with microcephaly. Part of his
assessment includes a TORCH test. In providing client
education, the nurse explains to the mother that TORCH
test will assess for:
a. Presence of the TORCH virus
b. Complications of pregnancy
c. Presence of one or more specific viruses
d. Evidence of thalidomide poisoning
(Answer: C) Rationale: The acronym TORCH stands for
toxoplasmosis, other (syphilis, hepatitis), rubella,
cytomegalovirus, and herpes simplex virus. It is a study
of common viruses that cause significant fetal damage.
108. A 4-month-old infant has been admitted with a
diagnosis of sepsis. The nurse would monitor the child
for evidence of:
a. Hypothermia
b. Rash
c. Sunken fontanels
d. Glucosuria
(Answer: A) Rationale: Neonates with sepsis may
display either hypothermia or hyperthermia, but
hypothermia is more common. The other symptoms are
not associated with sepsis.
109. A 12-year-old child with HIV + antibodies is going
home from the hospital. Which of the following are the
most important home-going instructions?
a. Growth and developmental milestones
b. Immunization schedules
c. Lab studies and results
d. Prevention of the spread of HIV
(Answer: D) Rationale: Families need to know that
casual contact cannot spread HIV. However, basic
infection control practices must be maintained t prevent
exposure through body fluids.
110. A 4-year-old has been exposed to chickenpox. After
the nurse has provided information about chickenpox,
the nurse asks the mother to repeat the information. The
statement by the mother that indicates a need for
additional information is:
a. “During the prodomal period, my child will have
pox all over his body.”
b. “Chickenpox is a viral infection that can be
spread to other children.”
c. “I should monitor my child for Reye syndrome,
which is a complication of chickenpox.”
d. “My child should not visit my pregnant sister at
this time.”
(Answer: A) Rationale: The prodomal period refers to the
period of time between the initial symptoms and the
presence of the full-blown disease. The rash would not
be apparent during this time. All the other statements are
correct.
111. An 18-month-old client is brought in for a well child
visit. The parent reports feeling a lump to the right of the
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“belly button” during bathing. Initial assessment should
not include:
a. Measuring weight and height
b. Further palpation often area
c. Performing urine testing
d. Taking vital signs
(Answer: B) Rationale: This is the usual presentation of
Wilms’ tumor (nephroblastoma), and palpating the area
may cause the tumor to spread. Since Wilm’s tumor is a
cancer of the kidney, it important to assess growth and
development, kidney function, and blood pressure, which
may be elevated because of increased rennin
production.
112. The parent of a child with neuroblastoma verbalizes
regret at not coming in earlier for the client’s complaints.
An appropriate response is:
a. This tumor may be diagnosed early because of
obvious symptoms
b. This is a silent tumor, which is difficult to
diagnose early
c. This is a very common brain tumor in children
d. This is the most common childhood cancer
(Answer: B) Rationale: This tumor occurs in 1 in 10,000
live births. It arises out of embryonic neural crest cells
and, therefore, is usually found in the adrenals or
retroperitoneal sympathetic chain. Symptoms are vague
and depend on location.
113. A 4-year-old is diagnosed with acute lymphocytic
leukemia. Following teaching about the testing and
therapy, the nurse evaluates the family’s understanding
of the problem. The statement by the family that
indicates appropriate knowledge would be:
a. “Tests will determine the extent of the tumor
process and support the need for palliation.”
b. “Tests will help to determine if radiation or
chemotherapy should be used in the treatment
plan.”
c. “Tests will determine if surgery is needed.”
d. “Tests will determine the extent of eth malignant
process and stage the leukemia.”
(Answer: D) Rationale: Acute lymphocytic leukemia is
stages at diagnosis to determine treatment. The goal is
remission, which is usually accomplished using
chemotherapy. Radiation therapy to the central nervous
system is rarely used because of untoward side effects.
114. A school health nurse would suspect a brain tumor
after noting the presence of which of the following
symptoms that is compatible with this health problem?
a. Ataxia and irritability
b. Papilledema and positive red reflex
c. Headache and vomiting
d. Fever and seizures
(Answer: C) Rationale: The most common reported
symptoms of brain tumors in children are headache,
especially upon awakening, and vomiting that is
unrelated to eating. Both are related to increased
intracranial pressure. Irritability and ataxia may also be
present; however, presenting symptoms are often
vague. Fever is not a symptom of a brain tumor.
Papilledema may be noted, but red reflex is not
indicative of brain tumors.
115. An adolescent is being admitted for an amputation
related to a bone tumor. Which age-related nursing
diagnosis is most appropriate?
a. Risk for disuse syndrome
b. Body image disturbance
c. Self-care deficit
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 d. Activity intolerance
(Answer: B) Rationale: Bone tumors usually occur in
other wise healthy children. Given the interruption of
normalcy and the developmental tasks of the
adolescent, body image disturbance can occur when a
limb is lost.
116. A child has been treated with chemotherapy for
cancer. Neutropenia is an expected consequence. The
nurse would teach the parents to do which of the
following, anticipating that neutropenia may occur?
a. Avoid contact sports
b. Avoid crowded spaces
c. Avoid spicy foods
d. Avoid all immunizations
(Answer: B) Rationale: Neutropenia is a reduced white
blood cell count, which increases the risk for infection.
Only live vaccines are contraindicated in children who
are immunocompromised. Contact sports would be a
problem with thrombocytopenia, and spicy foods would
increase discomfort if an alteration in mucous
membranes occurred.
117. A child diagnosed with Ewing’s sarcoma is being
treated with chemotherapy. The results of a complete
blood count (CBC) indicate severe thrombocytopenia.
Nursing interventions related to this finding would
include:
a. Encouraging foods high in iron
b. Limiting physical contact with the child
c. Removing fresh flowers from the child’s room
d. Clearing the floor of the child’s room to prevent
falls and bruises
(Answer: D) Rationale: Thrombocytopenia refers to a
decrease in platelets. Preventing falls and bruises would
be appropriate for an individual with platelet deficiencies.
Fresh flowers may contain molds and fungus that can
lead to infection and would be a concern for a child wit
neutropenia. Providing foods high in iron would be
appropriate to restore red blood cells. Limiting contact
with the child could affect his or her body image and self-
esteem. Contact is acceptable as long as the individual
is not infectious.
118. The parents of a child with neutropenia secondary
to chemotherapy have been taught protective isolation
behaviors. Nursing observations that indicate a need for
further education is when the parents:
a. Bring the child toys from home
b. Encourage friends to visit by phone rather than
visit
c. Pull the child in a wagon around the nursing unit
for entertainment
d. Wash their hands before entering the child’s
room but not upon exiting the room
(Answer: C) Rationale: Healthy children are often a
source of infectious organisms. Children in hospitals
may carry a number of infectious organisms.
Hospitalized neutropenic children should be protected
from exposure to other children whenever possible. Toys
form home would not carry a higher risk. Hand washing
before contact with the child is the important
intervention. Limiting physical contact with peers would
decrease exposure to infectious organisms. Telephone
contacts allow for the peer support the child needs.
119. Following diagnosis of Wilms’ tumor, the child
undergoes removal of the affected kidney. In the post-
operative period, priority-nursing assessments should
focus on:
a. The incision
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b. Lung sounds
c. Temperature
d. Kidney function
(Answer: D) Rationale: All of these assessments look at
possible postoperative complications. Since the child is
left with only one kidney, failure of that kidney caused by
inadequate blood flow, infection, or any other cause
could be fatal.
120. A child will be undergoing chemotherapy. The
nurse discusses the issue of hair loss with the child and
family before chemotherapy begins. Later the family
questions the nurse on why this information was given to
the child at this time. The nurse’s response will include
the information that:
a. Hair loss is a symptom of toxic blood levels of
chemotherapy, so the child should be watching
for this phenomenon
b. The presence or absence of hair is related to
body image. Strategies for handling hair loss
should precede the event.
c. It is the nurse’s legal responsibility to discuss
this issue with the child
d. Hair loss can be prevented with appropriate
nursing interventions
(Answer: B) Rationale: Preparation helps individuals
handle stressful situations. If the child had not been
prepared for hair loss, it could be more anxiety provoking
for the child. Hair loss cannot be prevented.
121. An 18-month-old child with a history of cleft lip and
palate has been admitted for palate surgery. The nurse
teaches the parents not to use a toothbrush immediately
after surgery because:
a. The Toothbrush would be frightening to the child
b. The child no longer has deciduous teeth
c. The suture line could be interrupted
d. The child will be NPO
(Answer: C) Rationale: During the immediate
postoperative period, protecting the operative site is a
priority in the nursing care of this child. A toothbrush
should be a familiar object to an 18-month-old child.
Deciduous (primary) teeth are still present at this age
and are replaced by permanent (secondary) teeth
around 6 years of age. Oral care will be performed
according to the physician’s orders but usually consists
of cleansing the area with sterile water.
122. The nurse instructs the parents about the
postoperative feeding schedule following their infant’s
pyloromyotomy. The nurse evaluates that the parents
understand the instructions when they state they may
begin feedings:
a. 6 hours postoperatively
b. 8 hours postoperatively
c. 10 hours postoperatively
d. 12 hours postoperatively
(Answer: A) Rationale: Clear liquids are usually
prescribed 4 to 6 hours after surgery.
123. Shortly after the delivery of an infant with an
omphalocele, the nurse would initially:
a. Weigh the infant
b. Insert an orogastric tube
c. Call the blood bank for 2 units of blood
d. Cover the sac with moistened sterile gauze
(Answer: D) Rationale: Omphalocels are congenital
malformations in which abdominal contents protrude
through the umbilical cord. A translucent sac covers the
protrusion; immediately after birth, the sac requires
priority attention. The sac is covered with sterile gauze
11
soaked in normal saline solution to prevent drying and
injury.
124. While gathering admission data on a 16-month-old
child, the nurse notes all the following abnormal findings.
Which finding is related to a diagnosis of Hirschsprung’s
disease?
a. Projectile vomiting lacking bile
b. Decreased urine output
c. Weights less than expected for height and
weight
d. Intermittent sharp pain
(Answer: C) Rationale: Infants with Hirschsprung’s
disease usually display failure to thrive, with poor weight
gain and delayed growth. Projectile vomiting is usually
associated with pyloric stenosis. Decreased urine output
and intermittent sharp pain are nonspecific symptoms
that can be associated with many different diseases and
disorders.
125. A 6-week-old boy is brought into the pediatrician’s
office with a history of frequent vomiting after feedings
ands failure to gain weight. The diagnosis of
gastroesophageal reflux is made and discharge
instructions are begun. While planning discharge
teaching on feeding techniques with the parents, the
nurse should include instructions to:
a. Dilute the formula
b. Delay burping to prevent vomiting
c. Change from milk-based formula to soy-based
formula
d. Position the infant at a 30 to 45 degree angle
after feedings
(Answer: D) Rationale: Small, frequent feedings followed
by placing the infant at a 30 to 45 degree angle has
been shown to be beneficial in treating
gastroesophageal reflux. Diluting the formula would not
be recommended because the infant needs the calories
from the full-strength formula. It may be recommended
to thicken the formula with rice cereal. It is
recommended to burp frequently; to delay burping would
only increase the occurrences of reflux.
Gastroesophageal reflux is not related to milk
intolerance so changing the formula would not help the
child.
126. A 14-year-old boy is brought into the Emergency
Department with a diagnosis of rule out appendicitis. He
is complaining of right lower quadrant pain. The nurse’s
most appropriate action to assist in managing his pain
would be to:
a. Insert a rectal tube
b. Apply an ice bag
c. Apply a heating pad
d. Administer an intravenous antispasmodic agent
(Answer: B) Rationale: An ice bag may help relieve his
pain. A rectal tube is contraindicated because it
stimulates bowel motility, which would increase the pain.
A heating pad is contraindicated because it increases
the flow of blood to the appendix and may lead to
rupture. An antispasmodic agent would not be beneficial
for the pain associated with appendicitis. Antispasmodic
agents are typically used to inhibit smooth muscle
contractions.
127. The nurse has completed discharge teaching on
the dietary regimen of a child wit celiac disease. The
nurse recognizes that client education has been
successful when the mother states that the child must
comply with the gluten-free diet:
a. Throughout life
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b. Until the child has achieved all major
developmental milestones
c. Only until all symptoms are resolved
d. Until the child has reached adolescence
(Answer: A) Rationale: Discharge planning focuses on
educating the parents in maintaining a gluten-free diet
for the child. Dietary modifications are life long and
should not be discontinued when the child is symptom-
free. Symptoms will return if dietary restrictions are not
maintained.
128. An appropriate nursing assessment of an infants
suspected of having necrotizing enterocolitis would be:
a. pH evaluation of the stomach
b. Neurological status every 2 hours
c. Rectal temperature every 2 hours
d. Abdominal girth every 4 hours
(Answer: D) Rationale: Measuring the abdominal girth
frequently aids in early detection of necrotizing
enterocolitis, which, in turn, minimizes loss of bowel.
Assessment of stomach pH is not done. Frequent
assessment of the neurologic status is not specific to this
disease. Rectal temperatures are contraindicated
because of the increased risk of perforation.
129. The nurse is developing a teaching plan for the
parents of an infant diagnosed with hepatitis A. Which of
the following instructions would be included to reduce
the risk for transmission of this disease?
a. Disinfect all clothing and eating utensils on a
daily basis
b. Tell family members to wash their hands
frequently
c. Spray the yard to eliminate infected insects
d. Vacuum the carpets and upholstery to rid the
house of the infectious host
(Answer: B) Rationale: Hepatitis A is highly contagious
and is transmitted primarily through the fecal-oral route.
The virus is transmitted by direct person-to-person
contact or through ingestion of contaminated food or
water, especially shellfish growing in contaminated
water. The remaining answers are related to other
infectious diseases.
130. Which of the following signs would the nurse
recognize as an indication of moderate dehydration in a
preschooler?
a. Sunken fontanel
b. Diaphoresis
c. Dry mucous membranes
d. Decreased urine specific gravity
(Answer: C) Rationale: Mucous membranes typically
appear dry when moderate dehydration is observed.
Other typical findings associated with moderate
dehydration include restlessness with periods of
irritability (especially infants and young children), rapid
pulse, poor skin turgor, delayed capillary refill, and
decreased urine output. Both anterior and posterior
fontanels are closed in a preschool-aged child. The skin
is usually dry with decreased elasticity, not diaphoretic.
Urine specific gravity increases with decreased urine
output associated with dehydration.
131. The nurse has completed some child and family
education for a child diagnosed with thalassemia. The
medical plan of treatment includes blood transfusions
when the anemia reaches a severe point. Which
statement by the parents indicates a need for further
education?
a. “Because of the anemia, my child will need extra
rest periods.”
12
 b. “My child inherited this disorder from both of us.”
c. “We should be alert to periods when our child
seems paler than usual.”
d. “My child needs an iron supplement.”
(Answer: D) Rationale: A child diagnosed with
thalassemia who will receive multiple transfusions
throughout life will need chelation therapy for excessive
iron stores. An iron supplement would be inappropriate
in this child.
132. The nursing assistant is setting up a hospital room
preparing to admit a child with disseminated
intravascular coagulopathy. Which item would the nurse
remove from the set-up?
a. Rectal thermometer
b. Bedpan
c. Intravenous therapy start kit
d. Sphygmometer
(Answer: A) Rationale: Rectal temperatures can
traumatize the fragile rectal mucosa leading to bleeding
and should be avoided. The vital signs will need to be
measured on a regular basis. An intravenous start kit is
appropriate as the child will need plasma ands blood
products. A bedpan will be needed if the child is on bed
rest.
133. At a hemophilia camp, several children with injuries
arrive at the clinic at the same time. When prioritizing
care for the children, the child who requires the most
immediate care from the nurse is the child with:
a. A swollen knee
b. Abrasions on both arms
c. A slight head injury
d. A puncture wound in the foot
(Answer: C) Rationale: All of the injuries require nursing
care; however, the child with the head injury has a
potentially life-threatening injury and needs attention
before the other three.
134. A 14-year-old boy with sickle cell anemia is
admitted with severe pain in his abdomen and legs. He
asks why the doctor ordered oxygen when he is not
having any problems breathing. The nurse would reply
that the main therapeutic benefit of oxygen is to:
a. Prevent further sickling
b. Prevent respiratory complications
c. Increase the oxygen-carrying capacity of red
blood cells (RBCs)
(Answer: A) Rationale: RBCs sickle under conditions
where low oxygen concentrations exist; therefore,
administering oxygen will prevent additional sickling. The
oxygen has no effect on the oxygen-carrying capacity of
RBCs. It will not have an effect on development of
respiratory complications. It will not decrease the
potential for infection.
135. You are administering a liquid iron preparation to a
3-year-old with iron deficiency anemia. It will be most
appropriate to:
a. Mix the medication in his milk and give it to him
at lunch
b. Give the medication after lunch with a sweet
dessert to disguise the taste
c. Give the medication to him in a small cup and
allow him to sip it through a straw
d. Allow him to decide whether to take the
medicine with breakfast or dinner
(Answer: C) Rationale: Iron preparations should be
taken through a straw in order to prevent staining the
teeth. While it is generally best to give toddlers choices
in the hospital setting, the other options are not
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appropriate as iron is best absorbed on an empty
stomach.
136. The nurse is admitting a child newly diagnosed with
disseminated intravascular coagulopathy (DIC).
Although the physician has explained the plan of care to
the family, they continue to ask about each nursing
activity. The nurse notes that the family seems unable to
comprehend the answers. The nurse would:
a. Notify the doctor because the family seems to
have a comprehension problem
b. Ask the doctor to write down the information for
the family
c. Recognize that the family is under stress and
continue to answer their questions
d. Determine if they are an English-as-a-second-
language (ESL) family
(Answer: C) Rationale: In an acute care setting such as
a hospital and with a potentially life-threatening disease
such as DIC, the family may need help with coping with
the stress they are feeling. This stress often interferes
with communication. A patient response by the nurse
with repetition of information will allow the family to
absorb the information.
137. You are administering factor VIII to a child with
hemophilia. You should observe for which potential
complication during the infusion?
a. Fluid overload
b. Transfusion reaction
c. Emboli formation
d. Contracting AIDS
(Answer: B) Rationale: Factor VIII concentrate is a blood
product. Fluid volume overload is an unlikely concern, as
the factor will be given in a comparatively small volume
of fluid. There is no greater a chance of emboli formation
with administration of factor VIII than with any other IV
preparation. Concern as to contracting AIDS from
administration of a blood product is a long-term concern
related to multiple administrations. It is not a concern
during the actual administration of the factor.
138. As you make a plan of care for a child experiencing
a sickle cell crisis, you should base your actions on the
knowledge that the pain of a vaso-occlusive crisis is
caused primarily by:
a. Obstruction of small blood vessels
b. Sequestration of blood
c. Hepatosplenomegaly
d. Increased RBC destruction
(Answer: A) Rationale: As RBCs clump together, they
block small blood vessels, which can lead to tissue
ischemia, necrosis, and death. This is the chief cause of
pain during a vaso-occlusive crisis. Blood sequestration,
Hepatosplenomegaly, and increased RBC destruction
are not the primary causes of pain during a crisis.
139. Which of the following statements should be
included when teaching the parents of a 7-month-old
infant about preventing anemia?
a. Anemia for the duration of infancy is unusual as
infants use fetal iron stores until 18 months of
age
b. Cow’s milk is an excellent source of iron, and
infants should be changed from formula to milk
as soon as possible after 6 months of age
c. Milk is a poor source of iron, and infants should
be given solid foods high in iron such as cereals,
vegetables, and meats
d. Anemia can easily occur during infancy and all
infants should receive iron supplements
13
(Answer: C) Rationale: Anemia does occur easily infancy
and infants have limited stores of iron. The first solid
food offered to infants is often cereal, which is an
excellent source if iron. All infants do not require iron
supplements; it is preferable that the iron comes form
dietary intake.
140. What precautions should the nurse take when
discontinuing an IV for a child with alterations in platelet
function?
a. Restrict movement of the arm for 12 hours
b. Obtain a culture of the tip of the IV catheter
c. Place steri-strips over site and have child hold
the arm above heart level for 15 minutes
d. Apply direct pressure to the site for at least 5
minutes
(Answer: D) Rationale: Alterations in platelet function
necessitate treating a break in the skin’s integrity as you
would an arterial stick – apply pressure for 5 minutes or
more. The goal of treatment is to apply pressure long
enough that the defective clotting mechanism will have
time to form a clot. Steri-strips would close the wound
adequately, and restricting arm movement will not assist
in the initial formation of a clot.
141. After writing a suicide note, a 16-year-old swallows
numerous anti-anxiety pills belonging to a friend. Which
of the following factors would indicate to you that the
teenager is at risk for a repeated attempt at suicide?
a. She stated that she wishes she hadn’t made
such a “stupid mistake.”
b. Her grades have dropped over the past few
weeks
c. Her father died recently
d. She lives with her mother and stepfather
(Answer: C) Rationale: Parental loss is a risk factor
associated with suicide. A decline in grades is a
symptom exhibited before her first suicide attempt, and
without further investigation, there is no indication that
there is a dysfunctional relationship between her and the
mother or stepfather. Indicating remorse for the action is
a positive step towards recovering.
142. When performing a health screening on an
adolescent in the health clinic, you would determine he
is at a higher risk of suicide than other adolescents of his
age based on which of the following facts that he
discloses?
a. He states that hw sleeps late on the weekends
b. He states that he only has a small group of close
friends
c. He states that he is a homosexual
d. He states that he often skips meals and does
not worry about nutrition
(Answer: C) Rationale: Homosexual adolescents are at
an extremely higher risk of suicide than other
adolescents their age, especially if the family does not
offer support. Sleeping late on weekends and skipping
meals without concern for nutrition is normal for
adolescents, as is having a small group of close friends.
143. An 11-year-old female was discovered smoking
cigarettes in the school bathroom. The school nurse
should implement which of the following plans for this
school-aged children?
a. Assign the child to a peer-led program to teach
the consequences of smoking
b. Recommend that the child attend a community-
based smoking prevention program
c. Assign the child videos to view that demonstrate
the effects of smoking
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d. Assign the child to attend a session of health
class that deals with smoking
(Answer: A) Rationale: Options 2, 3, and 4 are
appropriate ongoing activities to promote substance
abuse prevention; however, peer-led programs have
proven to be the most successful when teaching children
about the hazards of substance and tobacco use and
abuse.
144. You are providing care to a toddler who has
ingested an unknown amount of his grandfather’s
medication, which is described as “a white pill.” The
physician has ordered the administration of syrup of
ipecac and activated charcoal. What action would you
take?
a. Question the order because syrup of ipecac and
activated charcoal are not to be used together
b. Administer the ipecac, and after the child vomits,
administer the activated charcoal
c. Administer the activated charcoal, then
administer the syrup of ipecac
d. Insert a nasogastric tube for the administration
of the syrup of ipecac and activated charcoal
(Answer: B) Rationale: Option 1 is incorrect as ipecac is
often given preceding the administration of activated
charcoal. To reduce the risk of aspiration, activated
charcoal should never be administered before syrup of
ipecac (option 3), and there is no indication to insert a
nasogastric tube. Administering the syrup of ipecac,
waiting for the child to vomit, then administering the
activated charcoal is the correct method.
145. A child is brought to the Emergency Department
with excessive drooling, edema of lips and tongue,
swollen mucous membranes, and is hypotensive and
tachycardic. Based on this initial assessment, you
suspect that the child has ingested which of the following
agents?
a. A corrosive agent
b. Aspirin
c. Hydrocarbons
d. Acetaminophen
(Answer: A) Rationale: Corrosive agents cause the signs
and symptoms listed. Indications of aspirin overdose are
nausea, vomiting, diaphoresis, and seizures.
Hydrocarbons cause nausea, vomiting, cyanosis, and
altered sensorium, ands acetaminophen causes nausea,
vomiting, diaphoresis, and later, jaundice.
146. You are the telephone triage nurse and have
received a call from a mother who states that her 4-year-
old son has ingested an unknown amount of aspirin. She
administered 15mL of syrup of ipecac 20 minutes ago,
but the child has not vomited yet. You instruct the
mother to take which of the following actions?
a. Wait 15 more minutes, then if the child still has
not vomited, take him to the Emergency
Department immediately
b. Take child to the Emergency Department
immediately
c. Repeat the 15mL of syrup of ipecac now, and
immediately take the child to the Emergency
Department
d. Repeat the syrup of ipecac, but increase the
dose to 30mL, and immediately take the child to
the Emergency Department
(Answer: C) Rationale: 15mL of syrup of ipecac can be
repeated once for a 4-year-old child who has not
vomited after 20 minutes. All children with accidental
poisonings should be taken to the Emergency
Department for evaluation and treatment even if vomiting
14
has occurred.
147. A 10-year-old child with mild mental retardation
wants to join his younger brother’s Cub Scout group. His
parents are apprehensive about allowing him to join and
ask you for advice. Your response will be based on the
fact that children with mental retardation:
a. Have the same need for socialization as children
without mental retardation
b. Should not be encouraged to participate in clubs
because of their developmental delay
c. Should participate in clubs especially created for
children that are cognitively impaired
d. Do not have a need for socialization
(Answer: A) Rationale: Children with mental retardation
have the same need for socialization as others and
should be encouraged to participate in clubs and
activities with children of the same developmental age.
There is no need to encourage participation only in clubs
exclusive to children with cognitive impairment; this
would limit the child’s social interaction.
Radiologic examination reveals fractured ribs and a
healed fractured humerus. Based on these findings, your
next course of action would be which of the following?
a. Report the child as a victim of child abuse
immediately
b. Ask the father to provide further details of the
incident, obtain a medical history of the child,
and then interview the child separately
c. Ask the father if he has been physically abusive
to the child
d. Ask the father if he believes the child’s mother
has been physically abusive to the child
(Answer: B) Rationale: It is important to establish a
thorough history and a detail of the incident before
making assumptions of abuse. The child is safe from
harm in the Emergency Department, allowing time to
adequately assess the situation. You should not make
premature assumptions (option 1), and if abuse is
suspected, you should not inform the parent (option 3
and 4).

148. An 11-year-old child with attention deficit

hyperactivity disorder (ADHD) being treated with
methylphenidate (Ritalin) twice a day reports that he is
having difficulty falling to sleep at night. Upon
questioning him, you discover he is taking the
medication in the morning before leaving for school and
in the evening after supper. Based on the information
provided, you would instruct him in which of the
following?
a. Continue taking the morning dose as previously,
but take the evening dose earlier in the
afternoon
b. Stop taking the medication until he can be
evaluated by his physician
c. Take both doses of the medication in the
morning before leaving for school
d. Reduce the evening does of medication t half
the prescribed dose
(Answer: A) Rationale: Ritalin is a central nervous
system (CNS) stimulant, and if taken in the later
evening, may cause insomnia. The medication should
not be discontinued unless ordered by a physician, nor
should the dosages be adjusted without the physician’s
instructions.

149. The parents who have just experienced the death

of an infant from sudden infant death syndrome (SIDS)
request time alone with the infant. You should take
which of the following actions?
a. Discourage the parents from seeing the infant
because it will be too painful PRETEST:
b. Allow the parents as much time alone with the 01. Play during infancy is:
infant as they need a. Initiated by the child
c. Allow the parents to view the infant, but remain b. A way of teaching how to share
in the room with them c. More important than in later years
d. Deny the parents’ request because they are d. Mostly used for physical development
emotionally distraught
(Answer: B) Rationale: Parents need the opportunity to 02. The primary task to be accomplished between 12
hold their infant and to say goodbye in private for as long and 15 months of age is to learn to:
as they need. A peaceful, quiet, supportive environment a. Use a spoon
should be provided. Options 1, 3, and 4 are incorrect, as b. Climb stairs
they do not demonstrate compassionate care for parents c. Walk
who have just experienced the death of a child. d. Say simple words

150. A 3-year-old child is brought to the Emergency
Department for treatment of injuries the father stated
were obtained when the child fell off of his tricycle. Upon
assessment, numerous bruised areas, old and fresh, are
noted on the child’s back, buttocks, and shoulders.
03. Preschool children role-play. This is an important
part of socialization, since it:
a. Encourages expression
b. Helps children think about careers
c. Teaches children about stereotypes

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 d. Provides guidelines for adult behavior
04. Learning processes associated with a particular
stage of development often are referred to as
“developmental tasks.” A characteristic of developmental
tasks is that:
a. There is no uniform time of learning a task
b. Tasks are learned at the same age in children
c. Tasks occur with predictable rhythm
d. Most development tasks are learned by school
age
05. Parents can predispose their children to problems
with nutrition by using food in early childhood as a
means of:
a. Socializing
b. Reward and punishment
c. Acculturation
d. Teaching discipline
06. The major influence on eating habits of the early
Schoolage child is the:
a. Example of parents at mealtime
b. Food preferences of the peer group
c. Availability of food selections
d. Smell and appearance of food
07. Selection of drugs of choice for the treatment of
pneumonia depends primarily on:
a. Selectivity of the organism
b. Tolerance of the client
c. Preference of the physician
d. Sensitivity of the organism
08. Mrs. Legere and her son Johnny are seen at the
clinic. They both have severe upper respiratory tract
infections, and the physician plans to prescribe
tetracycline (Achromycin). The nurse reminds him that
Johnny is 6 years old and that Mrs. Legere is in her
eighteenth week of pregnancy. The data are important
because the drug may cause:
a. Persistent vomiting when given to small children
and pregnant women
b. Tooth enamel defects in children under 8 years
of age and in the maturing fetus
c. Lower red blood cell production at times in their
development when anemia is a common
problem
d. Changes in the bone structure of young children
and pregnant women
09. A viral infection characterized by red blotchy rash
and Koplik’s spots in the mouth is:
a. Rubeola
b. Rubella
c. Chickpox
d. Mumps
10. Under certain circumstances the virus that causes
chickenpox can also cause:
a. Athlete’s foot
b. Infectious hepatitis
c. Herpes zoster
d. German measles
11. Using live virus vaccines against measles is
contraindicated in children receiving corticosteroids or
antineoplastic or irradiation therapy because these
children may:
a. Have had the disease or have been immunized
previously
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
b. Be unlikely to need this protection during their
shortened life span
c. Be allergic to rabbit serum, which is used as a
basis for these vaccines
d. Be susceptible to infection because of their
depressed immune response
12. An injection consisting of bacterial cells that have
been modified is:
a. A vaccine
b. An antitoxin
c. A toxoid
d. A toxin
13. A child comes to the hospital after exposure to
diphtheria and is given antitoxin. This type of immunity is
known as:
a. Active natural immunity
b. Active artificial immunity
c. Passive natural immunity
d. Passive artificial immunity
14. Immunity by antibody formation during the course of
a disease is:
a. Active natural immunity
b. Active artificial immunity
c. Passive natural immunity
d. Passive artificial immunity
15. A viral disease that begins with respiratory
inflammation and skin rash and may result in grave
complications is:
a. Rubeola
b. Rubella
c. Yellow fever
d. Chickenpox
16. Mary has received her primary immunizations, so her
mother asks the nurse which ones should receive prior
to starting kindergarten. The nurse suggests the
following booster doses:
a. DTP, OPV
b. Measles, DTP
c. OPV, rubella
d. DTP, tuberculin test
17. Occasionally infants are born without an immune
system. They can live normally with no apparent
problems during their first months after birth because:
a. Limited antibodies are produced by the fetal
thymus during the eighth and ninth months of
gestation
b. Antibodies are passively received from the
mother through the placenta and milk
c. Limited antibodies are produced by the infant’s
colonic bacteria
d. Exposure to pathogens during this time can be
limited
18. James, a 2-year-old child, is admitted to the hospital
with a diagnosis of pneumonia. He is given antibiotics,
forced fluids, and oxygen. James’s temperature
continues to rise until it reaches 103F (39.4C). The
nurse calls the physician at the mother’s request, but the
physician sees no cause for alarm or change in
treatment, even though James has a history of
convulsions during previous periods of high fever.
Although the nurse is concerned, she takes no further
action. Later James has a convulsion that results in
neurologic impairment of the left arm and leg. Legally:
16
 a. The nurse’s actions did not derive from
observations, client’s history, or scientific fat
b. The physician’s decision takes precedence over
the nurse’s concern
c. High temperatures are common in children, and
this situation presented little cause for undue
concern
d. The physician is totally responsible for the
client’s health history and treatment regimen
19. Four-year-old Bobby has a seizure disorder and has
been taking phenytoin (Dilantin) for 3 years. An
important nursing measure for Bobby would be to:
a. Offer the urinal frequently
b. Administer scrupulous oral hygiene
c. Check for pupillary reaction
d. Observe for flushing of the face
20. When teaching parents at the school about
communicable disease, the nurse reminds them that
these diseases are serious, and that encephalitis can be
a complication of:
a. Chickenpox
b. Pertussis
c. Poliomyelitis
d. Scarlet fever
21. A viral disease caused by one of the smallest human
viruses that infect the motor cells of the anterior horn of
the spinal cord is:
a. Rubeola
b. Rubella
c. Poliomyelitis
d. Chickenpox
22. A Streptococcus infection characterized by swollen
joints, fever, and the possibility of endocarditis and death
is:
a. Whooping cough
b. Measles
c. Tetanus
d. Rheumatic fever
23. A skin infection that can be a sequela of a
staphylococcal infection or glomerulonephritis is:
a. Herpes simplex
b. Scabies
c. Intertrigo
d. Impetigo
24. A small toddler is admitted to the hospital because of
sudden hoarseness and an insistence on continuous
and somewhat unintelligible speech. In talking with the
mother, the nurse will be particularly concerned about:
a. Acute respiratory tract infection
b. Undetected laryngeal abnormality
c. Respiratory tract obstruction due to a foreign
body
d. Retropharyngeal abscess
25. An infection caused by the yeast Candida albicans
often occurring in infants and debilitated individuals is:
a. Typhoid fever
b. Thrush
c. Malta fever
d. Dysentery
26. A mother talks to the nurse about her sick infant and
she is disturbed because she did not realize the baby
was ill. A major indication of illness in an infant is:
a. Longer periods of sleep
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b. Grunting and rapid respirations
c. Profuse perspiration
d. Desire for increased fluids during the feedings
27. Among the last signs of heart failure in the infant and
child is:
a. Rapid respiratory rate in the supine position
b. Orthopnea
c. Tachypnea
d. Peripheral edema
28. A newborn of a few hours appears to be les cyanotic
when he cries. The nurse should observe for:
a. Twitching of the body resulting form neural
damage
b. Unequality of chest expansion associated with
atelectasis
c. Alterations in heart rate associated with an
atrioventricular septal defect
29. A mother brings her week-old newborn to the clinic
because he continually regurgitates. Chalasia is
suspected. The nurse instructs the mother to:
a. Keep the infant prone following feedings
b. Not permit the infant to cry for prolonged periods
c. Keep the infant in a semisitting position,
particularly after feedings
d. Administer a minimum of 8 oz of formula at each
feeding
30. The best legal definition of assault is:
a. The application of force to another person
without lawful justification
b. Threats to do bodily harm to the person of
another person
c. A legal wrong committed by one person against
the properly of another
d. A legal wrong committed against the public and
punishable by law through the state and courts
31. In legal terminologies, the term battery means:
a. Doing something that a reasonable person with
the same education or preparation would not do
b. A legal wrong committed by one person against
the property of another
c. The application of force to the person of another
person without lawful justification
d. Maligning the character of an individual while
threatening to do bodily harm
32. Dietary treatment of PKU includes a:
a. Low-phenylalanine diet
b. Phenylalanine-free diet
c. Dietary supplement for phenylalanine
d. Protein-free diet
33. Alan, age 3 months, has been diagnosed as having
cretinism. If care is not instituted until after early infancy,
he will probably:
a. Have myxedema
b. Be somewhat mentally retarded
c. Have abnormal deep tendon reflexes
d. Have thyrotoxicosis
34. Three-month-old Lisa is diagnosed as having
cretinism. She is to receive thyroxine sodium, 0.35 mg,
QD-PO. The medication is available in elixir form, 0.25
mg/mL. The nurse should administer:
a. 0.8 mL
b. 1.4 mL
c. 0.6 mL
d. 1.0 mL
17

35. Three-year-old Karen Allen may have celiac disease.
One symptom common in children with celiac disease is
stool that is:
a. Large, frothy, dark green
b. Small, pale, mucoid
c. Large, pale, foul smelling
d. Moderate, green, foul smelling
36. Mrs. Joyce asks the nurse how to tell the difference
between measles (rubeola) and German measles
(rubella). The nurse tells Mrs. Joyce with rubeola the
child has:
a. A high fever and Koplik’s spots
b. Symptoms similar to a cold, followed by a rash
c. Nausea, vomiting, and abdominal cramps
d. A rash on the truck with pruritus
37. A physician orders a tap water enema for 6-month-
old Bart. The nurse considers that a tap water enema
could:
a. Cause a fluid and electrolyte imbalance
b. Increase his fear of intrusive procedures
c. Result in shock form a sudden drop in
temperature
d. Results in loss of necessary nutrients
38. Chickenpox can sometimes be fatal to children who
are receiving:
a. Antibiotics
b. Steroids
c. Anticonvulsants
d. Insulin
39. The nurse explains to the parent group that the most
important complication of mumps in postpubertal males
is:
a. Decrease in libido
b. Hypopituitarism
c. Sterility
d. A decrease in androgens
40. Paula, a 3-year-old with eczema of the face and
arms, has not heeded the nurse’s warnings to “stop
scratching – or else!” The nurse finds Paula scratching
so intensely that her arms are bleeding. With great flurry,
the nurse ties Paula’s arms to the crib sides saying, “I’m
going to teach you one way or another.” In this situation,
the nurse:
a. Had to protect Paula’s skin and acted as any
reasonably prudent nurse would do
b. Tried to explain to Paula and rightly expected
her to understand and cooperate
c. Has used actions that can be interpreted as
assault and battery
d. Has merely done her job with considerable
accountability
41. Nancy, age 8, is receiving tetracycline (Achromycin).
Her fever is down and secretions have lessened; but she
is eating poorly, s withdrawn, lethargic, and irritable, and
sobs readily. The nurse should promptly discuss the
problem with the physician because:
a. She needs a higher food intake to fight the
infection
b. Anemia is a frequent occurrence after infection
and treatment with antibiotics
c. Concurrent bladder infection may be present as
an extension of her gram-negative infection
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d. Generalized physical symptoms and behavior
problems may precede drug-induced lvier
damage
42. Fourteen-year-old Evelyn is severely hurt while on a
skateboard and develops muscle contractures in all her
limbs. She refuses to move, so the nurse should
encourage her by:
a. Explaining that some pain is inevitable
b. Allowing friends to visit every day
c. Permitting her to make decisions regarding her
care
d. Setting strict limits to increase her security
43. Nine-year-old Harold has a fractured femur and a full
leg cast has just been applied. Which of the following
observations made by the nurse should be reported to
the physician immediately?
a. Pedal pulse of 90
b. Cast still damp and warm after 4 hours
c. Inability to move the toes
d. Increased urinary output
44. Two-year-old Jimmy swallowed kerosene from a
soda bottle stored in the garage. Immediate treatment
for ingestion of petroleum distillates is to have the child
swallow:
a. Milk of magnesia
b. Strong tea
c. Weak salt solution
d. Mineral oil
45. A toddler has swallowed liquid drain cleaner
containing lye. The immediate intervention is to
administer:
a. Syrup of ipecac
b. Two ounces of milk
c. Dilute vinegar solution
d. Sodium bicarbonate and water
46. Susan is found by her mother playing with an open
bottle of diuretic tablets. The physician tells Susan’s
mother to give syrup of ipecac to Susan. The effect of
the drug will be enhanced by:
a. Resting until vomiting occurs
b. Drinking 2 to 3 glasses of water
c. Actively playing until vomiting occurs
d. Stimulating the gag reflex
47. The primary reason for using prednisone in the
treatment of acute leukemia in children is that it is able
to:
a. Suppress mitosis in lymphocytes
b. Reduce irradiation edema
c. Decrease inflammation
d. Increase appetite and sense of well-being
48. A combination of drugs, which includes vincristine
(Oncovin) and prednisone, is prescribed for a child with
leukemia. Because of their toxicity the nurse should
expect:
a. Neurologic symptoms
b. Irreversible alopecia
c. Anemia and fever
d. Gastrointestinal symptoms
49. Which of the following responses is unusual in
infants subjected to prolonged hospitalization?
a. Lack or slowness of weight gain
b. Looking at ceiling lights rather than at persons
caring for them
18
 c. Limited emotional response to stimuli
d. Excessive crying and clinging when approached
50. A characteristic of infants and young children who
have experienced maternal deprivation is:
a. Extreme activity
b. Proneness to illness
c. Responsiveness to stimuli
d. Tendency toward overeating
51. Naomi, 9 years old, is about to have surgery. The
physician orders meperidine (Demerol), 20mg, IM
preoperatively. The container reads “50mg/ml.” The
nurse should administer:
a. 0.6 ml
b. 0.4 ml
c. 0.8 ml
d. 1.0 ml
52. An infant scheduled for surgery is diagnosed as
having a diaphragmatic hernia. Measures that the nurse
would expect to be employed at this time include:
a. Positive pressure oxygen by mask
b. Positive pressure oxygen by endotracheal tube
c. Increased oxygen concentration by any method
d. Humidity of 40%
53. It is expected that, after some surgical intervention
for atelectasis, lung expansion will recur within:
a. 1 hour
b. 48 to 72 hours
c. 4 hours
d. 12 to 48 hours
54. Dina, 18 months old, is to receive 5% dextrose and
Ringer’s lactate, 1000mL IV, in 24 hours. The drop factor
of the minidropper is 60 drops/ml. The nurse should
regulate the IV to run at:
a. 34 drops per minute
b. 38 drops per minute
c. 42 drops per minute
d. 21 drops per minute
55. When picked up by either the mother or the nurse,
an 8-month-old infant screams. The scream seems to be
that of pain. At his clinic visit the nurse will note and talk
particularly to the mother about:
a. The infant’s food and specific vitamins given to
him, including vitamins given to him, including
vitamins C and D
b. Accidents and injuries and the importance of
their prevention
c. Any other behavior of the infant that may have
been noticed by the mother
d. Limiting the play time and activities that this
infant has with other children in the family
56. Eleven-year-old Harry has gained weight. His mother
is concerned that Harry, who loves sports, may become
obese. The nurse:
a. Urges a decreased caloric intake
b. Explains this is normal for a preadolescent
c. Advises an increase in activity
d. Discusses the relationship of genetics and
weight gain
57. Exposure to hepatitis B may be expected to occur in
hospitals because of:
a. Needle sticks and mucous membrane exposure
b. Careless handling of excreta by staff
c. Newer treatments for hemophilia A
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d. Increasing use of ventilating systems
58. Elouise, 8 months old, has a gastrostomy tube and is
given 240mL of tube feeding q2h. One of the primary
nursing responsibilities at the time of the feeding is to:
a. Elevate the tube 30cm (12 inches) above the
mattress
b. Give 10mL of normal saline before and after
feeding
c. Position on the right side after feeding
d. Open the tube 1 hour before feeding
59. Prior to administering a gastrostomy tube feeding to
an infant, the nurse should:
a. Slowly instill 5mL of water
b. Aspirate the tube
c. Provide the baby with a pacifier
d. Place in a semi-Fowler’s position
60. Sal has been admitted to the hospital for surgery to
correct his congenital megacolon. Enemas are ordered
preoperatively to cleanse the bowel. The nurse should
use:
a. Soap suds
b. Hypertonic phosphate
c. Isotonic saline
d. Tap water
61. If monocular strabismus is not corrected early
enough:
a. Vision in both eyes will be diminished
b. Peripheral vision will disappear
c. Dyslexia will develop
d. Amblyopia develops in the weak eye
Situation: Mr. Crew, a nursing student, is doing
therapeutic play wit the children in the playroom of the
well-baby clinic. To understand how to plan for children
of various ages, he needs to have knowledge of their
developmental norms. Questions 62 through 65 refer to
this situation.
62. Mr. Crew observes that 2-year-old Mark:
a. Builds houses with blocks
b. Is very possessive of toys
c. Attempts to stay within the lines when coloring
d. Amuses himself with a picture book for 15
minutes
63. Mr. Crew observes 4-year-old Colin having difficulty
playing with the other children. He understands that it is
normal for Colin to:
a. Exaggerate and boast to impress others
b. Have pierce temper tantrums and negativism
c. Engage in parallel or solitary play
d. Be almost totally dependent on parents
64. Fifteen-month-old Nadia is playing in the playpen.
Mr. Crew observes her activities and realizes that her
physical tasks are within the norms when she is able to:
a. Build a tower of six blocks
b. Stand in the playpen holding onto the sides
c. Throw all the toys out of the playpen
d. Walk across the playpen with ease
65. Mr. Crew would encourage two 6-year-old boys in
the playroom to play with:
a. A board game
b. An erector set
c. Checkers
d. Clay
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Situation: Mr. And Mrs. Bee were emotionally upset
when their baby girl Sue was born with a cleft palate and
double cleft lip. Questions 66 through 70 refer to this
situation.
66. To give the most support to the parents, the nurse
should:
a. Discourage them form talking about the baby
b. Encourage them to express their worries and
fears
c. Tell them not to worry because the defect can
be repaired
d. Show them postoperative photographs of babies
who had similar defects
67. The most critical factor in the immediate care of Sue
after repair of the lip is:
a. Maintenance of a patent airway
b. Administration of drugs to reduce oral secretions
c. Administration of parenteral fluids
d. Prevention of vomiting
68. Additional nursing care for Sue after the surgical lip
repair would include:
a. Placing the infant in a semisitting position
b. Keeping the infant from crying
c. Spoon feeding for the first 2 days after surgery
d. Keeping the baby NPO
69. At 2 years of age Sue returned for palate surgery.
The most important factor in preparing her for this
experience is:
a. Her previous hospital visits
b. Gratification of all her wishes
c. Never leaving her with strangers
d. Assurance of affection and security
70. A toothbrush would not be used on Sue immediately
after palate surgery because:
a. The suture line might be injured
b. She was not accustomed to a brush at home
c. She probably has no teeth
d. It might be frightening to her
Situation: David, age 1 year, weighs 12.6 kg (28
pounds) but is pale and lethargic. His hemoglobin level
is 5 g and he has an enlarged heart. When taking a
nursing history form his mother, the nurse learns that he
refuses food so she gives him a quart of milk per day
from a bottle. Questions 71 through 77 refer to this
situation.
71. The nurse suggests that his mother:
a. Put a large hole in the nipple and put baby food
in with his milk
b. Take him to the metabolic clinic for a checkup
c. Immediately begin the weaning process
d. Give him finger foods such as raisins and
chopped meat
72. David should have been started on solid foods by at
least 5 or 6 months of age because:
a. His fetal reserve of iron was depleted
b. It would have taught him how to chew
c. His bone marrow activity has slacked off at this
time
d. It would have helped control his weight
73. The most prevalent nutritional disorder among
children in the United States is iron deficiency anemia. A
major reason for this in young children is:
a. Overfeeding of milk
b. Lack of adequate iron reserves from the mother
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c. Blood disorders
d. Introduction of solid foods too early for proper
absorption
74. Anemia, a nutritional problem encountered in
children and adults, involves several different nutrients.
The nutrients include proteins, iron, vitamin B12, and:
a. Carbohydrates
b. Thiamine
c. Calcium
d. Folic acid
75. The food that the nurse would emphasize to David’s
mother as a source of iron to be included in his diet daily
is:
a. Orange juice
b. Lamb
c. Mineral-fortified cereal
d. Milk
76. David’s mother also states that he has eight teeth
and asks when she should take him to the dentist. For
dental prophylaxis, the nurse encourages her to take
him:
a. The next time another family member goes to
the dentist
b. Before starting school
c. Between 2 and3 years of age
d. When he begins to lose his deciduous teeth
77. The nurse’s background knowledge of the basic
nutrients that act as partners in building red blood cells
will form the basis for a teaching plan. These nutrient
partners of iron are:
a. Calcium and vitamins
b. Carbohydrates and thiamine
c. Proteins and ascorbic acid
d. Vitamin D and riboflavin
Situation: Four-year-old Ann weighs 18 kg (40 pounds)
and is in a private pediatric room on “gown, glove, and
linen precautions.” She was admitted for weight loss,
anorexia, viginitis, and insomnia. A diagnosis of pinworm
infestation was made. Questions 78 through 82 refer to
this situation:
78. The most effective time for the nurse to collect a
cellophane tape test for p8inworms is:
a. At bedtime before bathing
b. Just following a BM
c. Immediately after meals
d. Early morning before arising
79. Pinworms cause a number of symptoms besides
anal-itching. A rare sequela of pinworm infestation that
the nurse should observe for is:
a. Pneumonitis
b. Stomatitis
c. Hepatitis
d. Appendicitis
80. Pyrvinium pamoate (Povan) is an effective single-
dose drug to eliminate pinworms. How many milligrams
will Ann receive if 5 mg per kilogram of body weight are
ordered?
a. 90 mg
b. 18 mg
c. 40 mg
d. 200 mg
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81. After administering Pyrvinium pamoate (Povan) to
Ann, it is important to alert the staff that a normal side
effect of this drug is that it colors the stool or vomitus:
a. Dark brown
b. Light green
c. Bright red
d. Gentian blue
82. The nurse’s decision to alert the staff is based on the
knowledge that:
a. Irritation by pinworms in the rectum may cause
ulceration and bleeding
b. The cyanine dye origin of the drug colors the
stool
c. The stool contains hemoglobinlike metabolic
products of disintegrating pinworms
d. The drug is irritating to the intestinal mucosa and
may cause transient bleeding
Situation: Seven-year-old Johnny has been admitted for
a tonsillectomy. Questions 83 through 85 refer to this
situation:
83. An essential nursing action preoperatively is to:
a. Encourage parent to stay until Johnny goes to
the operating room
b. Provide him with his favorite toy
c. Observe his ASO titer
84. The nurse suspects hemorrhage postoperatively
when Johnny:
a. Snores noisily
b. Becomes pale
c. Complains of thirst
d. Swallows frequently
85. Johnny is complaining of pain in his throat. Which of
the following medications for pain would be best for him
at this time?
a. Aspirin, 300mg
b. Tylenol, 300mg
c. Phenobarbital, 15mg
d. Demerol, 50mg
Situation: Two-day-old Edward has a 94. In reviewing his immunizations for the past 10
meningomyelocele. He is scheduled for surgery.
Questions 86 through 88 refer to this situation:
86. Prior to the surgical correction, a primary nursing
goal in caring for a child with a meningomyelocele is to:
a. Observe for bowel and bladder dysfunction
b. Prevent infection
c. Prevent skin breakdown
d. Observe for increasing paralysis
87. After closure of Edward’s meningomyelocele, it is
essential that his nursing care include:
a. Decrease of environmental stimuli
b. Strict limitation of leg movement
c. Measurement of head circumference daily
d. Observation of serous drainage from the nares
88. To meet a major developmental need of Edward’s
the nurse should:
a. Provide a soft cuddly toy
b. Give him a pacifier
c. Warm his formula before feeding
d. Put a mobile over his crib
Situation: Eight-year-old John Kee is being discharged
following treatment for sickle cell crisis. He is allowed to
return to school and resume normal activities. Questions
89 through 93 refer to this situation.
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89. The nurse explains to Mrs. Kee that a very important
aspect of care for John at home should include:
a. At least 14 hours sleep per day
b. Rigorous exercise and play
c. Ingestion of large quantities of liquids
d. High-calorie diet
90. Infants with sickle cell anemia may not be diagnosed
as having this disorder because of:
a. The presence of fetal hemoglobin during the first
year of life
b. Compensation of increased hematocrit and
hemoglobin if well fed
c. Absence of respiratory disorders
d. General good health and an excellent growth
curve
91. The sickling process of the red blood cell occurs in
conditions of:
a. Hemodilution
b. Hypoxia
c. Thrombocytopenia
d. Hypocalcemia
92. To prevent thrombus formation in capillaries, as well
as other problems form stasis and clotting of blood in the
sickling process, the main nursing intervention is:
a. Administration of oxygen
b. Increasing fluids by mouth and a humidifier
c. Complete bed rest
d. Use of heparin or other anticoagulants
93. Common nursing care that helps prevent both sickle
cell crisis and celiac crisis is:
a. Limitation of activity
b. Protection from infection
c. High-iron, low-fat, high-protein diet
d. Careful observation of all vital signs
Situation: Johnny Smith, 12 months of age, is brought
to the pediatric health clinic for a regular physical
assessment. Questions 94 through 98 refer to this
situation.
months the nurse would expect him to have been
immunized against:
a. Measles, rubella, polio, tuberculosis, and
pertusis
b. Polio, Pertussis, tetanus, and diphtheria
c. Measles, mumps, rubella, and tuberculosis
d. Pertussis, tetanus, polio, and measles
95. Mrs. Smith asks the nurse how the DTP injection
works. The nurse, in formulating a response, recalls that
in active immunity:
a. Blood antigens are aided by phagocytes in
defending the body against pathogens
b. Protein antigens are formed in the blood to fight
invading antibodies
c. Protein substances are formed by the body to
destroy or neutralize antigens
d. Lipid agents are formed by the body against
antigens
96. The measles immunization is usually routinely given
after 15 months of age because of the:
a. Increased hazard of side effects in infants
b. Presence of maternal antibodies during the first
year
c. Interference it causes with effectiveness of
pertussis, diphtheria, and tetanus immunizations
21
 d. Rare incidence of measles infection prior to 12
months of age
97. Infants receive immunizations made up of attenuated
viruses. This means that these immunizations:
a. Contain passive antibodies
b. Contain active antibodies
c. Cause the development of passive antibodies
d. Cause the development of active antibodies
98. In terms of preventive teaching for a 1-year-old, the
nurse would speak to Mrs. Smith about:
a. Adequate nutrition
b. Accidents
c. Sexual development
d. Toilet training
Situation: Nancy Hand, a 5-year-old only child, is
admitted to the hospital with pneumonia. She requires
bed rest, a soft diet, liberal fluid intake, and ampicillin,
250 mg, po qid. She is restless and fretful and tells the
nurse she feels sick. Questions 99 through 104 refer to
this situation.
99. The immediate priority in Nancy’s nursing care is:
a. Nutrition
b. Rest
c. Exercise
d. Elimination
100. Nursing care likely to be most effective in alleviating
Nancy’s fretfulness is:
a. Giving her a jigsaw puzzle
b. Putting her in a room by herself
c. Letting her play with a doll
d. Reading a story to her
101. The best choice of between-meal nourishment for
Nancy is:
a. Fresh fruit
b. Hard candy
c. Skim milk
d. Creamed soup
102. When the nurse brings her dinner tray Nancy says,
“I’m too sick to feed myself.” The nurse should respond:
a. “Try to eat as much as you can.”
b. “Be a big girl and don’t act like a baby.”
c. “Let it go until you feel better.”
d. “Wait 5 minutes and I will help you.”
103. Nancy’s statement is most likely indicative of:
a. Immaturity
b. Loneliness
c. Regression
d. Temper tantrum
104. Nancy is apathetic about eating. Nursing care
directed toward supporting her nutrition should include:
a. Providing Diversional activity at mealtime
b. Eliminating all between-meal nourishment
c. Asking her parents to visit at mealtime
d. Giving her only the foods she likes best
Situation: Mrs. Bronson is informed that her infant
daughter has phenylketonuria (PKU). Questions 105
through 108 refer to this situation.
105. Which of the following statements is true
concerning PKU?
a. PKU is transmitted by an autosomal dominant
gene
b. The infant is tested for PKU immediately after
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delivery
c. If PKU is untreated, mental retardation occurs
d. Treatment for PKU includes life-long diet therapy
106. A test that was done on Baby Bronson in the
nursery to detect PKU is:
a. Guthrie blood test
b. Ferric chloride urine test
c. Phenistix test
d. Clinitest serum phosphopyruvic acid
107. When teaching Mr. and Mrs. Bronson about their
daughter’s disorder, the nurse should state that:
a. Phenylalanine is not necessary for growth
b. Other amino acids can be increased to
substitute for phenylalanine
c. A low-phenylalanine diet is required
d. Phenylalanine can be administered to correct
the deficiency
108. In terms of dietary counseling, the parents need
much help and support in adhering to specific regimens.
A frequent question asked by parents is, “How long will
my child have to be on this diet?” An appropriate
response by the nurse is:
a. “Unfortunately, this is a life-long problem and
dietary management must always be
maintained.”
b. “Usually, if the child does well for 1 year, she
then can gradually begin eating regular foods.”
c. “As of now, research shows that a child needs to
be on this diet until she is about 6 to 8 years of
age. Then she can gradually begin to eat other
foods.”
d. “No one knows, but why don’t you discuss it with
your doctor.”
Situation: Mrs. Simmons brings 3-year-old Sam to the
emergency room, indicating he has had a fever for
several days, has held his neck rigid, and is now
vomiting. While being examined he has a convulsion and
is admitted to the pediatric unit. Questions 109 through
114 refer to this situation.
109. While instituting nursing measures to reduce Sam’s
fever, the nurse recognizes that an important
consideration is to:
a. Monitor vital signs every 10 minutes
b. Force oral fluids
c. Measure output every hour
d. Limit exposure to prevent shivering
110. One morning, while Sam is in crib, the nurse notes
his jaws are clamped and he is having a seizure. The
most important nursing responsibility at this time is to:
a. Insert a padded tongue blade
b. Start oxygen at 10L by mask
c. Protect Sam from harm from the environment
d. Restrain Sam to prevent injury to soft tissue
111. Febrile convulsions are common in children and:
a. Usually occur after the first year of life
b. The cause is usually readily identified
c. May occur in minor illnesses
d. Occur more frequently in females than males
112. The physician orders acetaminophen 150mg, po,
q4h, and prn for fever above 101F (38C). The nurse
has on hand a bottle labeled “1 tablet equals 80mg.” The
nurse should administer:
a. ½ Tablet
b. 1 Tablet
22
 c. 1 ½ Tablet
d. 2 Tablet
113. Sam is diagnosed as having meningococcal
meningitis. The nurse observes Sam for the:
a. Identifying purpuric skin rash
b. Continual tremors of the extremities
c. Low-grade nature of the fever
d. Palatal paralysis and glossitis
114. The most serious complication of meningitis in
young children is:
a. Hydrocephalus
b. Blindness
c. Peripheral circulatory collapse
d. Epilepsy
Situation: Three-month-old Matt Quincy is admitted to
the hospital with bile-stained vomitus and abdominal
distention. Questions 115 through 118 refer to this
situation.
115. The nurse should also observe for:
a. Constant severe pain and absence of stools
b. Bounding pulse and hypotonicity
c. Paroxysmal pain and grunting respirations
d. High-pitched cry and weak thready pulse
116. Prior to surgery for the intestinal obstruction, Matt is
kept NPO and has a Levin tube in place. To calm Matt
and also to meet his developmental needs best, the
nurse should:
a. Allow him to suck on a pacifier
b. Hang a brightly colored mobile in his crib
c. Place him on his abdomen and permit him to
crawl
d. Allow him to hold his favorite toy
117. Matt develops diarrhea postoperatively and is given
IV fluids. The nurse to must observe the rate of flow
often:
a. Avoid IV infiltration
b. Prevent increased output
c. Prevent cardiac embarrassment
d. Replace all fluids lost
118. When Mrs. Quincy returns to the surgical clinic for
follow-up care, the nurse includes the following
preventive suggestion in her teaching:
a. Remove all tiny objects from the floor
b. Keep crib rails up to the highest position
c. Cover electric outlets with safety plugs
d. Remove poisonous substances from low areas
Situation: Five-year-old Sam has been hospitalized with
acute glomerulonephritis. Questions 119 through 122
refer to this situation:
119. The nurse observes Sam primarily for:
a. Polyuria, high fever
b. Dehydration, hematuria
c. Hypertension, circumocular edema
d. Oliguria, hypotension
120. When planning nursing care for Sam, the nurse
realizes that he needs help in understanding his
restrictions, one of which is:
a. Bed rest for at least 4 weeks
b. A bland diet high in protein
c. Daily doses of IM penicillin
d. Isolation from other children with infections
121. The average 5-year-old is incapable of:
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a. Making decisions
b. Tying his shoelaces
c. Abstract thought
d. Hand-eye coordination
122. Sam loves to ride his bike, and his parents are very
concerned about his activity when he returns home. The
nurse bases the answer to them the fact that after the
urinary findings are nearly normal:
a. He must remain in bed for 2 weeks
b. Activity does not affect the course of the disease
c. He must not play active games
d. Activity must be limited for 1 month
Situation: Sue Green, a 2-year-old girl, is admitted to
the pediatric unit with respiratory wheezing, dyspnea,
and cyanosis. One of the tentative diagnoses is cystic
fibrosis. Questions 123 through 129 refer to this
situation.
123. Cystic fibrosis can predispose Sue to bronchitis
mainly because:
a. Tenacious secretions obstruct the bronchioles
and respiratory tract and provide a favorable
medium for growth of bacteria
b. Increased salt content in saliva can irritate and
necrose mucous membranes in nasopharynx
c. Neuromuscular irritability causes spasm and
constriction of the bronchi
d. The associated heart defects of cystic fibrosis
cause congestive heart failure and respiratory
depression
124. The problem of cystic fibrosis is sometimes first
noted by the nurse in the newborn nursery because of
the infant’s:
a. Increased heart rate
b. Abdominal distention
c. Excessive crying
d. Sternal retractions
125. Sue is small and underdeveloped for her age
primarily because she:
a. Ingested little food for several months because
of poor appetite
b. Was unable to absorb nutrients because of a
lack of pancreatic enzymes
c. Secreted less than normal amounts of pituitary
growth hormone
d. Developed muscular and bony atrophy from lack
of motor activity
126. When caring for the child with cystic fibrosis and the
nurse should:
a. Perform postural drainage
b. Encourage active exercise
c. Prevent coughing
d. Provide small frequent feedings
127 The foul-smelling, frothy characteristic of the stool in
cystic fibrosis results from the presence of large
amounts of:
a. Sodium and chloride
b. Semidigested carbohydrates
c. Undigested fat
d. Lipase, trypsin, and amylase
128. Medications that will probably be used for Sue in
her therapeutic regimen include:
a. A steroid and an antimetabolite
b. Antibiotics, a multivitamin preparation, and
cough drops
23
 c. Pancreatic enzymes and antibiotics
d. Aerosol mists, decongestants, and fat-soluble
vitamins
129. In cystic fibrosis, frequent stools and tenacious
mucus often produce:
a. Intussusception
b. Anal fissures
c. Meconium ileus
d. Rectal prolapse
Situation: Two-year-old Mike Coz is admitted to the
hospital for the second surgical repair of is clubfoot. Mrs.
Coz cannot stay overnight with her son, since visiting
hours are restricted. On the morning after admission,
Mike is standing in his crib crying. He refuses to be
comforted and calls for his mother. Questions 130
through 133 refer to this situation:
130. The nurse approaches Mike to bathe him and he
screams louder. This behavior is recognized as the
stage of protest, and the nurse:
a. Picks him up and walks with him around the
room
b. Sits by his crib and bathes him later when his
anxiety decreases
c. Decides he really does not need a bath when he
is this upset
d. Fills the basin with water ands proceeds to
bathe him
131. On the third postoperative day Mike begins to
regress and lies quietly in his crib with his blanket. The
nurse recognizes that Mike is in the stage of:
a. Denial
b. Mistrust
c. Rejection
d. Despair
132. During his second week of hospitalization, Mike
smiles easily, goes to all the nurses happily, and does
not express a great deal of interest in his mother when
she visits. After leaving Mike’s room, Mrs. Cox tells the
nurse she is pleased that Mike is adjusting well but
expresses some concern about his reactions to her.
Before responding to Mrs. Cox, the nurse should
understand Mike-s behavior and realize that he:
a. Is repressing his feelings for his mother
b. Has established a routine and feels safe
c. Feels better physically so his behavior has
improved
d. Has given up fighting and accepts the
separation
133. The nurse explains the meaning of Mike’s behavior
to Mrs. Cox and tells her that after he goes home she
should expect that:
a. Mike will miss the nurses and hospital routine
b. It will be easier for Mike to adjust to his home
situation
c. Mike will continue his happy, normal behavior
d. It will take some time before the mother-child
relationship is reestablished
Situation: Sara, 12 years old, was diagnosed at the
orthopedic clinic as having idiopathic scoliosis. Proper
exercising and avoidance of fatigue are essential
components of Sara’s care. Questions 134 through 136
refer to this situation:
134. Early in Sara’s treatment the nurse can suggest
which of the following sports as therapeutic?
a. Bowling
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b. Swimming
c. Badminton
d. Golf
135. To assist her curvature correction, Sara is fitted
with a Milwaukee brace. The nurse explains to Sara and
her parents that the length of time the brace must be
worn varies but it is usually worn until:
a. Cessation of bone growth at the time of physical
maturity
b. The curvature of the spine is completely
straightened
c. Pain on prolonged standing diminishes
d. The iliac crests are at equal levels
136. One of the earliest signs of sexual maturity in a
young girl such as Sara is:
a. Interest in the opposite sex
b. Attention to grooming
c. An increase in the size of the breasts
d. The appearance of axillary and pubic hair
Situation: At 2 weeks of age Baby Williams begins to
vomit after his feedings and is admitted to the hospital
for observation with a tentative diagnosis of pyloric
stenosis. Questions 137 through 141 refer to this
situation.
137. The nurse should carefully observe him for:
a. Signs of dehydration
b. Coughing and gagging after feeding
c. Quality of cry
d. Quality of stool
138. When vomiting is uncontrolled in an infant, the
nurse should observe for signs of:
a. Tetany
b. Alkalosis
c. Acidosis
d. Hyperactivity
139. The maintenance of fluid and electrolyte balance is
more critical in children than in adults because:
a. Renal function is immature in children below the
age of 4
b. Cellular metabolism is less stable than in adults
c. The proportion of water in the body is less than
in adults
d. The daily fluid requirement per unit of body
weight is greater than in adults
140. What is the most critical actor confronting the nurse
in the administration of IV fluids to a small, dehydrated
infant?
a. Maintenance of the prescribed rate of flow
b. Maintenance of the fluid at body temperature
c. Calculation of the total necessary intake
d. Assurance of sterility
141. Surgery is performed and Baby Williams’ condition
is stable. The nurse caring for him notices that is post-
operative orders are similar to those for other infants
having undergone such surgery and include:
a. Withholding all feedings for the first 24 hours
b. Additional glucose feedings after the first 24
hours
c. Thickened formula 24 hours after surgery
d. Diluted formula feeding 24 hours after surgery
Situation: Karen Vale, a 5-year-old girl, is admitted to
the hospital 1 week before surgery for tetralogy of Fallot.
Questions 142 through 146 refer to this situation:
24
142. The defects associated with this heart anomaly
include:
a. Right ventricular hypertrophy, atrial and
ventricular defects, and mitral valve stenosis
b. Right ventricular hypertrophy, ventricular septal
defect, stenosis of pulmonary artery, and
overriding aorta
c. Origin of the aorta from the right ventricle and of
the pulmonary artery from the left ventricle
d. Abnormal connection between the pulmonary
artery and the aorta, right ventricular
hypertrophy, and atrial septal defects
143. A common finding in most children with cardiac
anomalies is:
a. Mental retardation
b. Cyanosis and clubbing of fingertips
c. A family history of cardiac anomalies
d. Delayed physical growth
144. Karen is to receive digoxin (Lanoxin) elixir,
0.010mg, po. Based on developmental norms for a 5-
year-old, the nurse would withhold the medication and
notify the physician if the apical rate is below:
a. 60 beats per minute
b. 80 beats per minute
c. 90 beats per minute
d. 100 beats per minute
145. Karen’s laboratory analysis indicates a high red
blood cell count. This polycythemia can best be
understood as a compensatory mechanism for:
a. Cardiomegaly
b. Low iron level
c. Low BP
d. Tissue oxygen need
146. Karen undergoes heart surgery to repair the
anomaly. Postoperatively it is essential that the nurse
prevent:
a. Constipation
b. Unnecessary movement
c. Crying
d. Coughing
Situation: Johnny, a 15-year-old, is taken to the
emergency room of the local hospital because he
stepped on a nail. Questions 147 and 148 refer to this
situation:
147. The puncture wound is cleansed and a sterile
dressing applied. While doing these tasks, the nurse
asks the mother if Johnny has been immunized against
tetanus. The reply is affirmative. Penicillin is
administered, and Johnny is sent home with instructions
to return if there is any change in the wound area. A few
days later, Johnny is admitted to the hospital with a
diagnosis of tetanus. Legally:
a. The possibility of tetanus could not have been
foreseen, since he had been immunized
b. The nurse’s judgment was adequate in view of
the client’s symptoms
c. Assessment by the nurse was incomplete and
the treatment was inadequate
d. Hospital protocol should govern treatment in
emergency room care
148. After Johnny’s admission, one of the most
important aspects of nursing care should be directed
toward:
a. Maintaining body alignment
b. Encouraging high intake of fluid
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c. Carefully monitoring urinary output
d. Decreasing external stimuli
Situation: Three-day-old Patty is diagnosed as having
congenital hip dysplasia. Questions 149 through 151
refer to this situation.
149. An early sign able to be observed by the nurse in
the newborn nursery is:
a. Limitation in adduction of the leg
b. Shortening of the leg on the unaffected side
c. Depressed dance reflex
d. Asymmetry of the gluteal folds
150. At 3 months of age Patty has a spica cast applied
from below the axilla to below the knee. To prevent a
serious complication that often occurs in infants in a
spica cast, the nurse teaches Patty’s parents to:
a. Seek immediate medical care if Patty develops a
cough
b. Limit movement to prevent cast damage
c. Change Patty’s diapers frequently
d. Feed Patty a low-calorie diet
151. When elevating Patty’s head, the nurse is aware
that it is important to:
a. Limit this position to 1 hour at a maximum
b. Raise the entire mattress and spring at the head
of the bed
c. Use at least two pillows under her shoulders
d. Place folded diapers at the edge of the cast
Situation: Working on a cardiac care unit, the nurse will
care for many children with a variety of congenital
anomalies. Questions 152 through 155 refer to this
situation.
152. Meg, 2 years old, has a cyanotic congenital heart
disease. The nurse would expect to observe:
a. Edema in the extremities
b. An elevated hematocrit
c. Absence of pedal pulses
d. Orthopnea
153. Baby boy Vics has been found to have a patent
ductus arteriosus, which is:
a. A narrowing of the pulmonary artery
b. An abnormal opening between the right and left
ventricles
c. A connection between the pulmonary artery and
the aorta
d. An enlarged aorta and pulmonary artery
154. The nurse is caring for a child with an acyanotic
heart disease. A major common symptom of acyanotic
heart disease is:
a. Polycythemia
b. Clubbing of fingers and toes
c. Severe retarded growth
d. The presence of an audible heart murmur
155. Alma has coarctation of the aorta. When taking her
vital signs, the nurse can expect to observe:
a. Weak, thready radial pulses
b. Higher BP in upper extremities
c. Bounding femoral pulses
d. Notching of the clavicle
Situation: Ten-year-old Jim Smith is admitted to the
emergency room after a car accident. However, normal
measures to stop his bleeding are unsuccessful, and, on
further study, Jim is found to have a mild case of classic
hemophilia. Mr. And Mrs. Smith is very concerned about
25
this and wonders how it happened. Questions 156 a. Lacks a swallow reflex
through 158 refer to this situation. b. Chokes on her feeding
156. In discussing hemophilia with Mr. and Mrs. Smith c. Pharynx and larynx
the nurse should explain that: d. Anal area
a. Hemophilia is an X-linked disorder in which the
mother is usually the carrier of the illness but is 164. When reviewing the data recorded on Nellie’s chart,
not affected by it the information that might indicate to the nurse that the
b. Hemophilia is an autosomal dominant disorder baby requires special attention would be:
in which the woman carries the trait a. Birth weight of 3500g
c. Hemophilia follows regular laws of Mendelian b. 20mL of milky-colored fluid aspirated from
inherited disorders such as sickle cell anemia stomach
d. This disorder can be carried by either male or c. The infant has a positive Babinski reflex
female but occurs in the sex opposite that of the d. The Apgar score at birth was 3
carrier
Situation: Three-year-old Roger is admitted to the
157. Jim’s parents are very worried about their other pediatric unit with a diagnosis of nephrosis. Questions
children, two girls and another boy, and want to know 165 through 168 refer to this situation.
what the chances are concerning their having the 165. The most important nursing intervention for Roger
disorder or being a carrier. An appropriate answer to this is:
question would be that: a. Encouraging fluids
a. All the girls will be normal and the other son a b. Regulating his diet
carrier c. Maintaining bed rest
b. Each son has a 50% chance of being a victim d. Preventing infection
and each daughter a 50% of being a carrier
c. All the girls will be carriers and one half the boys 166. As Roger gets older and has repeated attacks of
will be victims nephrosis, it is most important for the nurse to help him
d. Each son has a 50% chance of being either a develop:
victim or carrier, and the girls will all be carriers a. Fine muscle coordination
b. Acceptance of possible sterility
158. The most common site of internal bleeding in c. A positive body image
hemophiliacs is the: d. The ability to test his own urine
a. Cerebrum
b. Ends of the long bones
c. Intestines
d. Joints

Situation: Eight-year-old Cara has juvenile rheumatoid

arthritis. Drug therapy includes the administration of
sodium salicylate, 10gr, 4 times daily. Questions 159
through 161 refer to this situation:
159. During the salicylate therapy the nurse should
observe Cara for:
a. Nausea, dizziness, edema, headache
b. Gastric distress, nausea, vomiting, tinnitus
c. Constipation, deafness, nausea, headache
d. Diarrhea, gastric distress, edema of the face

160. Sodium salicylate is classified as an:

a. Antibiotic and antipyretic
b. Analgesic and antipyretic
c. Analgesic and sedative
d. Antipyretic and hypnotic

161. While Cara is in bed convalescing, she becomes

very bored and irritable. The nurse plans activities that a
school-age child would like and suggests she:
a. Play chess
b. Start a collection
c. Watch game shows on TV
d. Do arithmetic puzzles

Situation: Nellie, a newborn, is admitted to the pediatric

unit with the diagnosis of choanal atresia. Questions 162
through 164 refer to this situation.
162. Choanal atresia is an anomaly located in the:
a. Nasopharynx
b. Intestinal tract
c. Pharynx and larynx
d. Anal area

163. While feeding Nellie, the nurse notices that she:

St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339 26

PRETEST
01. The nurse has assessed four children of varying
ages; which one requires further evaluation?
a. A 7-month-old who is afraid of strangers
b. A 4-year-old who talks to an imaginary playmate
c. A 9-year-old with enuresis
d. A 16-year-old male who had nocturnal
emissions
(Answer: C) Rationale: The child may have a physiologic
or psychologic problem; all other answers indicate age-
appropriate situations.
02. The nurse is caring for a 5-year-old child who has
leukemia and is now out of remission and not expected
to survive. The child says to his mother, “Will you take
care of me when I am dead the way you do now?” The
child’s mother asks the nurse how to answer her child.
The nurse’s response should be based on which of the
following understandings of the child’s behavior?
a. The child is denying that he has a terminal
illness
b. The child may be hallucinating
c. Children of this age do not understand the
finality of death
d. Most 5-year-old children have a great fear of
mutilation
(Answer: C) Rationale: Preschool children do not
understand the finality of death. They often view it as a
long sleep. It is common for preschoolers to ask who will
take care of them when they die. Preschool children may
know the word dead but do not really comprehend what
it means. The child is not in denial or hallucinating; he is
behaving normally for his age. Fear of mutilation is more
common among school-age children. The statement as
given in the question does not describe mutilation.
03. The nurse is talking with the mother of a one-year-
old child in well-baby clinic. Which statement the mother
makes indicates a need for more instruction in keeping
the child safe?
a. “I have some syrup of ipecac at home in case
my child ever needs it.”
b. “I put all the medicines on the highest shelf in
the kitchen.”
c. “We have moved all the valuable vases and
figurines out of the family room.”
d. “My husband put the gates up the top and
bottom of the stairs.”
(Answer: B) Rationale: At one year of age babies are or
soon will be climbing on everything. Putting medicines
on the highest shelf is not sufficient. All medicines
should be put in a locked cabinet. Syrup of ipecac
should be in every home in case of accidental poisoning.
The poison control center may recommend a dose syrup
of ipecac. The family is wise to “baby proof” the house
rather than always saying “no” to the child. Moving
breakable valuable removes temptation from the child.
Putting gates up at the stairs will help to prevent falls.
04. Suzy Walker was born 6 weeks prematurely. She is
not 2 months old and her mother brings her to the clinic
for her checkup. Administration of DTaP will depend on:
a. The presence of sufficient muscle mass
b. Whether the vaccines are live or inactive
c. The Denver Developmental Screening results
d. Calculating her age by subtracting six weeks
from the due date
(Answer: A) Rationale: DTaP is given intramuscularly,
therefore administration is dependent on the presence of
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
sufficient muscle mass. The Denver Developmental
Screening is an assessment tool. Subtracting six weeks
from the due date because of prematurity is done for
developmental assessment, not for immunizations.
Administration of either live or inactive vaccines is not
contraindicated in prematurity.
05. Fifteen-month-old Anne is brought in for her regular
checkup. All of her immunizations are given as
recommended. Anne’s mother asks the nurse what
immunizations her daughter will receive today. The
nurse’s best response is that she is due for her:
a. Third DTaP
b. MMR vaccine
c. First Hib immunization
d. First OPV immunization
(Answer: B) Rationale: Current recommendations call for
measles, mumps, and rubella-combined vaccine (MMR)
to be given at 15 months. DTaP is given at 2, 4, and 6
months, followed by a booster 6 to 12 months after the
third dose. OPV is given at 2 to 4 months followed by
boosters between 12 and 24 months and between 4 and
6 years of age. Hib is given at 2, 4, and 6 months.
06. The presence of what condition would necessitate a
change in the standard immunization schedule for a
child?
a. Allergy to eggs
b. Immunosuppression
c. Congenital defects
d. Mental retardation
(Answer: B) Rationale: Immunosuppressed clients may
need alteration in immunization protection as live viruses
may overwhelm them. Mental retardation and congenital
defects would not interfere with the immunization
schedule unless neurologic defects were present. MMR
vaccine does contain eggs but a child allergic to eggs
would receive the vaccine on schedule in very small
doses at 20-minute intervals with adrenalin available
should anaphylaxis occur.
07. Jimmy Wilkins, 2 years old, is brought to the
pediatric clinic with an upper respiratory infection. After
assessing Jimmy, the nurse informs the physician that
she suspects this child may be a victim of child abuse.
Physical signs that almost always indicate child abuse
are:
a. Diaper rash
b. Bruises on the lower legs
c. Asymmetrical burns on the legs
d. Welts or bruises in various stages of healing
(Answer: D) Rationale: Injuries at various stages of
healing are symptomatic of child abuse. Bruises on the
lower legs are common occurrences in a healthy active
child. Diaper rash may be seen in a well-cared-for child.
Burns characteristic of child abuse usually have shapes
resembling the item used to burn the child, such as
cigarette butts.
08. Which parent-child interaction does NOT warrant
further assessment when child abuse is suspected? The
parent who:
a. Appears tired and disheveled
b. Is hypercritical of the child
c. Pushes the frightened child away
d. Expresses far more concern than the situation
warrants
(Answer: A) Rationale: Being tired and disheveled gives
no clue to parent-child interaction. The parent who
pushes the frightened child away, who is hypercritical of
the child, and who expresses far more concern than the
27
situation warrants exhibits extremes in behavior that are
seen frequently in parents who physically abuse their
children.
09. When child abuse is suspected, the nurse knows
that abusive burns will:
a. Have a number of scars
b. Have identifiable shapes
c. Display an erratic pattern
d. Be on one side of the body
(Answer: B) Rationale: Burns typical of child abuse have
symmetrical shapes and resemble the shape of the item
used to burn the child. When a child is burned
accidentally, the burns form an erratic pattern and are
usually irregular or asymmetrical. A number of scars are
inconclusive evidence of child abuse. When burning is
used as a means of physically abusing the child, the
burns are usually bilateral.
10. The mother of an eight-year-old brings her child to
the physician because the child has a “funny red circle”
on his leg. The mother reports that the child went on a
camping trip last weekend. The physician draws blood to
rule out Lyme disease and prescribed for a tick bite. The
nurse’s response is based on which of the following
understanding?
a. Lyme disease weakens the person so they are
susceptible to infections
b. Lyme disease is caused by a spirochete that is
sensitive to doxycycline
c. Doxycycline will kill the tick, which may still be in
the child
d. Antibiotics are given to cure the infection at the
site of the tick bite
(Answer: B) Rationale: Lyme disease is caused by a
spirochete that is sensitive to antibiotics. Lyme disease
does not make the client more susceptible to infections.
The tick will not be in the child. There is not likely to be
an infection at the site of the bite. The red bull’s eye
around the tick bite is not an infection.
11. The mother of a three-year-old child calls her nurse
neighbor in a panic state, saying that the child swallowed
most of a bottle of aspirin. The nurse determines that the
child is still alert. In addition to calling the poison control
center, the nurse should:
a. Induce vomiting in the child
b. Observe the child carefully until the ambulance
arrives
c. Immediately start CPR
d. Give the child lots of milk to drink
(Answer: A) Rationale: Since the child is still alert, the
nurse should plan to administer syrup of ipecac. If the
child were not conscious, he would be lavaged upon
arrival at the emergency room. There is no indication
that the child is not breathing; CPR in not indicated. It
would be better to remove the poison than to dilute it
with milk.
12. An eight-month-old infant was admitted to the
hospital with severe diarrhea and dehydration. Fluid
replacement therapy was initiated. Which observation
the nurse makes indicates an improvement in the
infant’s status?
a. Fontanels are depressed
b. Infant has gained 3 oz since yesterday
c. Skin remains pulled together after being gently
pinched and released
d. The infant’s hematocrit is greater today than
yesterday
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
(Answer: B) Rationale: A weight gain would suggest
greater circulating volume. Blood has weight. Depressed
fontanels are a sign of dehydration. AS the infant
improves, the fontanels should no longer be depressed.
The skin turgor should improve, not remain poor as
described in option 3. Hematocrit rises with dehydration.
There is less fluid in the blood and consequently a
greater portion of blood is red cells.
13. Jeffrey, age 17, has Down’s syndrome. He is 57
inches tall and weighs 155 pounds. In planning his care,
it is most important for the nurse to take into
consideration:
a. His mental age
b. His chronologic age
c. His bone age
d. Growth chart percentiles
(Answer: A) Rationale: All Down’s syndrome children are
retarded and care must be geared to their mental age.
The other measurements of age do not reflect the
special needs of these children.
14. Down’s syndrome is caused by:
a. An autosomal recessive defect
b. An extra chromosome
c. A sex-linked defect
d. A dominant gene
(Answer: B) Rationale: In Down’s syndrome there is an
extra chromosome on the 21st pair, which is why the
disease is also called trisomy 21. The mutation is
spontaneous and not inherited.
15. Louise was born with a myelomenigocele with
accompanying hydrocephalus. She has had a shunt
procedure to alleviate the hydrocephalus. Louise should
be placed in which of the following positions?
a. Trendelenburg’s
b. On her back
c. With her legs adducted
d. On her abdomen
(Answer: D) Rationale: Pressure must be kept off the
spinal sac. As there is paralysis of the lower extremities,
the legs should be abducted. Trendelenburg’s position is
contraindicated in hydrocephalus.
16. The nurse is caring for an infant who is born with
hydrocephalus. She has a shunt inserted. Which of the
following signs indicates that the shunt is functioning
properly?
a. The sunset sign
b. A bulging anterior fontanel
c. Decreasing daily head circumference
d. Widened suture lines
(Answer: C) Rationale: With improved draining of the
CSF, the head circumference should become smaller.
All the other signs indicate increased ICP.
17. Henry is a 13-year-old who has been diagnosed as
having epilepsy. A positive sign that Henry is taking his
Dilantin properly is:
a. Hair growth on his upper lip
b. Absence of seizures
c. Lowered hemoglobin and hematocrit
d. Drowsiness
(Answer: B) Rationale: Dilantin is an antiepileptic drug
that controls seizures. All the other signs ands
symptoms are side effects of the medication.
18. Jennifer Pine, 3-years-old, is admitted with a
diagnosis of viral meningitis. During an initial
assessment of Jennifer the nurse would expect to find:
28
 a. Headache, fever, and petechiae
b. Seizures, lethargy, and hypothermia
c. Pallor, anorexia, and bulging fontanels
d. Fever, irritability, and nuchal rigidity
(Answer: D) Rationale: The clinical symptoms of viral
meningitis (aseptic meningitis) include fever, irritability,
and stiffness of the neck (nuchal rigidity). Other
symptoms include drowsiness, photophobia, weakness,
painful extremities, and sometimes seizures. Aseptic
meningitis usually resolves within tow weeks. Headache
and fever may be seen in meningitis, but petechiae are
not. Seizures and lethargy may be seen in meningitis,
but hypothermia is not. Bulging fontanels are a sign of
hydrocephalus.
19. To meet the sensory need of a child with viral
meningitis, nursing strategies should include:
a. Minimizing bright lights and noise
b. Promoting active range of motion
c. Increasing environmental stimuli
d. Avoiding physical contact with family members
(Answer: A) Rationale: Photophobia and hypersensitivity
to environmental stimuli are common clinical
manifestations of meningeal irritation and infection.
Comfort measures include providing an environment that
is quiet and has minimal stressful stimuli. Promoting
active range of motion at this time would not be
beneficial. The client needs rest. Increasing
environmental stimuli would only exacerbate the
symptoms of photophobia and hypersensitivity. The
client needs quiet and rest. Viral meningitis is not
contagious so contact with family members is not
contraindicated.
20. When addressing the emotional needs of the parents
of a young child with meningitis, the primary focus
should be on:
a. Assuming all responsibility for physical care of
the child
b. Providing reassurance that the symptoms will
resolve within the week
c. Reinforcing information about the child’s
condition and plan of treatment
d. Explaining the importance of an optimistic
outlook when interacting with their child
(Answer: C) Rationale: Successful coping in times of
anxiety and stress requires that the nurse be available to
provide information that validates parental right to know
and participation in their child’s care. Honesty, patience,
and unhurried repetition of information are necessary to
support the family. The parents should not be expected
to assume all responsibility for the child’s physical care.
The symptoms will not necessarily resolve within a
week. An optimistic outlook is also important when
interacting with the child but it is not the primary focus.
21. Discharge teaching for the parents of a child who
had meningitis should include:
a. Engaging a tutor to assist with learning problems
b. Administering the prescribed antibiotic
c. Notifying the physician if her fever or headache
persists more that a few days after discharge
d. Encouraging Jennifer to resume normal
activities immediately
(Answer: C) Rationale: Parents should be instructed to
contact the physician if the child’s symptoms worsen or
persist. Te child recovering from viral meningitis should
show signs of feeling better a week after discharge. A
tutor may be necessary if cognitive function priority in
discharge teaching. Antibiotics are not indicated in the
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
treatment of viral meningitis. The client should resume
activities as tolerated in time.
22. Phillip, 6-years-old, is brought to the Emergency
Department unconscious after being hit by a car. The
most helpful information for the nurse performing the
neurological examination on Phillip is the nurse’s
knowledge of:
a. Normal growth and development
b. Phillip’s usual behavior and status
c. Phillip’s past medical history
d. Phillip’s growth and developmental progress
during infancy
(Answer: B) Rationale: The child’s usual behavior and
level of development is what provides critical information
about his pretrauma neurological function. This would
serve as baseline data, present prior to the injury. It is
important to know normal growth and development, but it
is not individualized to this child. Phillip’s past medical
history is important but is not the most helpful
information when doing the neurological exam.
23. The nurse is assessing a child who has a head injury
for the occulocephalic reflex (doll’s eyes). The nurse
understands that the doll’s eye reflex is present it the
child’s eyes:
a. Move in the same direction in which his head is
turned
b. Move in the direction opposite to which his head
is turned
c. Remain midline when his head is turned
d. Move to the medial aspect of the orbit when his
head is turned
(Answer: B) Rationale: The occulocephalic reflex occurs
if, when the head of an unconscious child is turned
rapidly in one direction, the eyes move in the opposite
direction. In the occulocephalic reflex, the eyes do not
move in the same direction in which the head is turned.
The eyes do not remain in the midline when the head is
turned. The eyes do not move to the medial aspect of
the orbit when the head is turned.
24. Phillip’s pupils are dilated and react sluggishly. This
is indicative of:
a. Barbiturate overdosage
b. Damage to the diencephalon
c. Damage to the sympathetic system
d. Damage to the parasympathetic system
(Answer: D) Rationale: When dilated pupils react
sluggishly or are non reactive, it is an indication that
there has been damage to the parasympathetic nervous
system, which controls the pupillary construction
response. Damage to the diencephalon would show
pupils that are small and reactive to light. Barbiturates
cause pupillary dilation. Damage to the sympathetic
nervous system would inhibit the normal dilation
response and would cause pupils to be constricted.
25. A 4-year-old with tetralogy of Fallot is seen in a
squatting position near his bed. The nurse should:
a. Administer oxygen
b. Take no action if he looks comfortable but
continue to observe him
c. Pick him up and place him in Trendelenburg’s
position in bed
d. Have him stand up and walk around the room
(Answer: B) Rationale: Squatting is a normal response to
a cyanotic heart defect. This position increases
pulmonary blood flow because it changes the
relationship between systemic and pulmonary vascular
resistance. The squatting position alone should increase
29
the child’s oxygen level, so administration of oxygen will
most likely not be necessary. Picking the child up and
placing him in a Trendelenburg position (head down)
decreases his pulmonary blood flow and makes it harder
for him to breathe. His cardiopulmonary status would not
allow him to walk around the room at this time.
26. Christopher, 2-month-old, is suspected of having
coarctation of the aorta. The cardinal sign of this defect
is:
a. Clubbing of the digits and circumoral cyanosis
b. Pedal edema and portal congestion
c. Systolic ejection murmur
d. Upper extremity hypertension
(Answer: D) Rationale: Coarctation of the aorta is
characterized by upper extremity hypertension and
diminished pulses in the extremities. These signs would
be seen in a child with a cyanotic heart defect. Pedal
edema and portal hypertension are seen in clients with
congestive heart failure secondary to many congenital
cardiac disorders. Systolic ejection murmurs are present
in a child with atrial septal defect.
27. When assessing the apical heart rate in infants and
toddlers, the point of maximal impulse (PMI) is:
a. Between the third and fourth left intercostal
space
b. Between the fourth and fifth left intercostal
space
c. At the fifth intercostal space to the right of the
midclavicular line
d. In the aortic area
(Answer: A) Rationale: The heartbeat is most easily
counted at the point of maximum impulse. From birth
through toddlerhood it is located between the third and
fourth left intercostal space. The PMI in an adult is
located at the fifth intercostal space inside the left
midclavicular line.
28. Two-week-old Jonathon has a patent ductus
arteriosus. Prior to administering digoxin the nurse
should:
a. Take the apical pulse for 30 seconds and
multiply by 2
b. Give the medication if his pulse is 92, but notify
the physician
c. Take the radial pulse for 1 full minute
d. Give the medication after finding that the pulse
is 135 beats/minute
(Answer: D) Rationale: The apical pulse is taken for 1 full
minute and the medication is withheld if the pulse is less
than 100 beats/minute.
29. The nurse is planning care for a two-week-old infant
who has a congenital heart defect. Which of the
following actions is not appropriate?
a. Using a soft “preemie” nipple for feedings
b. Providing passive stimulation
c. Allowing him to cry to promote increased
oxygenation
d. Placing him in orthopneic position
(Answer: C) Rationale: Crying expends already
decreased energy. All the other measures help to
compensate for the decreased cardiac output.
30. Alice White, 10-years-old, has been hospitalized for
two weeks with rheumatic fever. Alice’s mother
questions whether her other children can catch the
rheumatic fever. The nurse’s best response is:
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
a. The fact that you brought Alice to the hospital
early enough will decrease the chance of her
siblings getting it
b. It is caused by an autoimmune reaction an is not
contagious
c. You appear concerned that your daughter’s
disease is contagious
d. Your other children should be taking antibiotics
to prevent them from catching rheumatic fever
(Answer: B) Rationale: Rheumatic fever is an
autoimmune reaction to a streptococcal infection and is
limited to the person having the reaction. Rheumatic
fever is not a contagious disease.
31. A 10-year-old child is admitted with rheumatic fever.
In addition to carditis, the nurse should assess the child
for the presence of:
a. Arthritis
b. Bronchitis
c. Malabsorption
d. Oliguria
(Answer: A) A major symptom of rheumatic fever is
arthritis. Bronchitis is not seen with rheumatic fever.
Malabsorption is not seen with rheumatic fever. Oliguria
is not seen with rheumatic fever.
32. The Tates have one child with hemophilia. Mrs. Tate
wants to have another child and she asks the nurse what
her chances are of having another child with hemophilia.
The nurse’s best response is:
a. All of your daughters will be carriers of the
disease
b. If you have another son, there is almost a 100%
chance he will have hemophilia
c. If you have a son, there is a 50% chance he will
have hemophilia but none of your daughters will
have it
d. There is a 25% chance of having another child
with hemophilia
(Answer: C) Rationale: Hemophilia is inherited as an X-
linked recessive trait. If this family has another son, there
is a 50% chance that he will have the disease. If they
have a daughter, she will not have the disease but there
is a 50% chance that she will be a carrier of the disease.
33. John is 4-years-old and has been diagnosed as
having iron deficiency anemia. A liquid iron preparation
has been prescribed. When administering John’s
medication the nurse should:
a. Ask him if he wants to take his medicine
b. Mix the medication in his milk bottle and give it
to him at nap time
c. Allow him to sip the medication through a straw
d. Give the medication after lunch with a sweet
dessert t disguise the taste
(Answer: C) Rationale: Iron is given with a straw to
prevent staining the teeth. It is best absorbed on an
empty stomach in an acidic environment. Do not ask
toddlers if they want to take their medication. They are
likely to say no.
34. Todd, age 10, has hemophilia A and is admitted to
the hospital for hemarthrosis of the right knee. He is in
great deal of pain. Which of the following interventions
would aggravate his condition?
a. Applying an ice bag to the affected knee
b. Administering children’s aspirin for pain relief
c. Elevating the right leg above the level of his
heart
d. Keeping the right leg immobilized
30
(Answer: B) Rationale: Aspirin interferes with the clotting
mechanism. All the other measures listed will help
decrease bleeding or alleviate the associated pain.
35. Melissa Heller, 17-years-old, has had sickle cell
anemia since she was a toddler. Her brother has sickle
cell trait. The client with sickle cell trait:
a. Has a chronic form of sickle cell anemia
b. Has the most lethal form of the disease
c. Will transmit the disease to all children
d. Has some normal and some abnormal
hemoglobin cells
(Answer: D) Rationale: Clients with sickle cell trait inherit
only one defective gene. They can synthesize both
normal and abnormal hemoglobin chains. If two people
with sickle cell trait marry, some of their children may
inherit abnormal genes. It is not a lethal form of the
disease, nor is it sickle cell anemia.
36. The mother of a child with sickle cell anemia tells the
nurse that, when she was reading about sickle cell
anemia, she learned that sickled blood cells do not have
as long a life expectancy as normal red cells. The life
expectancy of a sickled blood cell is approximately:
a. 5 days
b. 15 days
c. 30 days
d. 60 days
(Answer: B) Rationale: The life span of a sickled cell is 6
to 20 days
37. The child with sickle cell anemia may exhibit:
a. Vitiligo
b. Hyperactivity
c. Mild mental retardation
d. Delayed physical development
(Answer: D) Rationale: Children with sickle cell disease
manifest an impairment of growth. They do not
experience mental retardation, hyperactivity, or Vitiligo
(abnormal pigmentation).
38. A child who has sickle cell anemia has developed
stasis ulcers on her lower extremities. This is due to:
a. Poor range of motion
b. Ruptured blood vessels
c. Impaired venous circulation
d. Hypertrophy of muscular tissue
(Answer: C) Rationale: The tissues of a client with sickle
cell disease are constantly vulnerable to microcirculatory
interruptions. The vessels do not actually rupture; they
are blocked with the defective cells. The stasis ulcers
are not related to range of motion. Hypertrophy of
muscular tissue does not occur with sickle cell anemia.
39. Which complication is associated with sickle cell
anemia?
a. Constipation
b. Hypothyroidism
c. Addison’s disease
d. Cerebrovascular accidents
(Answer: D) Rationale: The sudden appearance of a
stroke in sickle cell anemia is related to the
microcirculatory interruptions that are caused by the
sickled cell. The blood supply to the bowel may be
damaged; however, constipation is not a common
problem associated with sickle cell disease. Addition’s
disease and hypothyroidism are endocrine disorders that
are not related to sickle cell disease.
40. Both of Sammy’s parents carry the sickle cell anemia
trait. Sammy, 8-month-old, contracted chickenpox from
his brother and now is very weak, febrile, and anorexic,
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
and cries with pain with his wrists and elbows are
moved. He is admitted to the hospital with a diagnosis of
sickle cell crisis. Sammy’s mother asks the nurse why
Sammy has not been symptomatic before now. The best
response by the nurse would be:
a. High fetal hemoglobin protected Sammy against
sickling
b. His red blood cell levels remained normal
c. Maternal antibodies protected Sammy against
sickling
d. Sickle cell hemoglobin was not present until
about 1 year of life
(Answer: A) Rationale: High levels of fetal hemoglobin
inhibit sickling of red cells prior to the age of 6 months.
His red blood cell level may have been normal, but his
abnormal blood cells were protected by the fetal
hemoglobin. Maternal antibodies do not protect the
baby’s blood cells from sickling. The baby is still not a
year old.
41. In planning care for a child with newly diagnosed
sickle cell anemia, his mother should be taught that
vaso-occlusive crises might be prevented by:
a. Prophylactic administration of acetaminophen
b. Eating food with a high iron content
c. Exercising regularly
d. Promoting hydration
(Answer: D) Rationale: Promoting good hydration is a
major factor in maintaining the blood viscosity needed to
maximize the circulation of red blood cells. Good
hydration can help to minimize the severity of symptoms
should the child develop sickle cell crisis.
Acetaminophen would not be helpful in decreasing the
sickling process. Iron administration would be of no
value because in sickle cell anemia there is abnormally
shaped hemoglobin. The problem is not due to iron
deficiency. Regular exercise is important for children
with sickle cell disease, but it will not prevent a vaso-
occlusive crisis.
42. Jimmy had a tonsillectomy performed earlier in the
day. He is now 4 hours post-op. Which of the following is
an abnormal finding and a cause for concern?
a. An emesis of dried blood
b. Increased swallowing
c. Pink-tinged mucus
d. Jimmy’s complaints of a very sore throat
(Answer: Increased swallowing could be a sign of
hemorrhage from the surgical site. Vomiting of dried
blood would be expected following a tonsillectomy. Pink-
tinged mucus would be an expected finding. Complains
of a very sore throat would be expected following
surgery:
43. Kevin is 7-years-old and has been diagnosed as
having cystic fibrosis. Chest physiotherapy has been
ordered. Kevin’s chest percussion should be performed:
a. Before postural drainage
b. ½ hour before meals
c. Before an aerosol treatment
d. After suctioning
(Answer: B) Rationale: Chest percussion is done prior to
meals to prevent vomiting. It follows aerosol therapy and
positioning. Suctioning may be needed afterwards to
remove thick secretions after percussion has loosened
them.
44. The nurse is performing chest physiotherapy on a 6-
year-old child who has congestion in his left lower lobe.
The nurse should position the child on his:
a. Left side in semi-Fowler’s position
31
 b. Right side in semi-Fowler’s position
c. Left side in Trendelenburg’s position
d. Right side in Trendelenburg’s position
(Answer: D) Rationale: The affected lobe must be
uppermost to be drained by gravity.
45. An infant is being evaluated for possible cystic
fibrosis. The sweat test will show an elevation of which
electrolyte?
a. Chloride
b. Fluoride
c. Potassium
d. Calcium
(Answer: A) Rationale: There is increased excretion of
chloride in the sweat of children wit cystic fibrosis. A
chloride level of over 60 mEq/liter is diagnostic for the
disease.
46. Michael, 2-years-old, is admitted to the hospital with
cystic fibrosis. As a result of malabsorption, he is small
for his age. What dietary suggestions can the nurse
recommend to Michael’s mother to enhance his growth?
a. Low-fat, low-residue, and high-potassium diet
b. Low-carbohydrate, soft diet with no sugar
products
c. High-carbohydrate, high-fat diet with extra water
between meals
d. High-protein, high-calorie meals with skim-
milkshakes between meals
(Answer: D) Rationale: A client with cystic fibrosis lacks
pancreatic enzymes necessary for fat absorption. A diet
high in protein and calories is necessary to meet the
child’s growth needs. Between-meal snacks of skim-milk
milkshakes may be given to provide additional protein,
vitamins, and calories. The child needs carbohydrates. A
soft diet with sugar restriction is not soft diet with sugar
restrictions is not necessary. Fat must be restricted in a
client with cystic fibrosis.
47. The nurse is caring for a 2-year-old who has cystic
fibrosis. His mother asks why the child developed cystic
fibrosis. The nurse explains that cystic fibrosis:
a. Develops due to meconium ileus at birth
b. Is an autosomal recessive genetic defect
c. Occurs during embryologic development
d. Results from chromosomal nondysjunction that
occurred at conception
(Answer: B) Rationale: Cystic fibrosis is an autosomal
recessive genetic disease. If both parents have the
cystic fibrosis trait, each child has a 25% chance of
developing the disease, a 50% chance of not having the
disease. Meconium ileus (obstruction of the small
intestine in the newborn caused by impaction of thick,
dry, tenacious meconium) often occurs but is a result of
cystic fibrosis and is one of the earliest signs. Autosomal
disorders are hereditary and depend on the autosomes.
It is unrelated to embryological development. Autosomal
disorders are hereditary. Te abnormal recessive gene
present at conception.
48. A 2-year-old is admitted to the hospital and will need
t stay for several days. The child’s mother is unable to
stay overnight because there is no one to care for her
other children. The nurse recommends that she:
a. Leave something of hers with Michael and tell
him she’ll be back in the morning
b. Leave while he is in the playroom
c. Leave after he has faller asleep
d. Tell him she’ll be back in a few minutes after she
has dinner
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
(Answer: A) Rationale: Leaving something of his
mother’s with the child and telling him that she will be
back in the morning is the best approach in developing
trust between the mother and her child. Sneaking out
and not being truthful with the child does not allow the
child to develop trust. Lying to the child and giving him
false hope that the mother will return after supper is not
appropriate.
49. Albert is a 2-year-old who has cystic fibrosis. His
mother tells the nurse that the family is planning their
first summer vacation with Albert. She wants to know if
there are any special precautions needed because he
has cystic fibrosis. The nurse should tell her that children
with cystic fibrosis are particularly susceptible to:
a. Severe sunburn
b. Infectious diarrhea
c. Heat prostration
d. Respiratory allergies
(Answer: C) Rationale: Clients with cystic fibrosis are
pone to electrolyte imbalances due to increased loss of
sodium and potassium in their sweat. The mother should
avoid having her child become overheated and should
frequently replenish body fluids with water or fruit juices.
A child with cystic fibrosis is no more susceptible to
sunburn than any other child. Any young child should be
protected with sunscreen when in the sun for long
periods of time. A child with cystic fibrosis is no more
likely to get infectious diarrhea than any other child,
although they do have noninfectious diarrhea. A child
with cystic fibrosis is no more likely to have respiratory
allergies than any other child. A child with cystic fibrosis
will have respiratory problems but they will not
necessarily be allergy related.
50. Amy, 4-years-old, is admitted to the hospital for the
treatment of an acute asthma attack. Her health history
reveals that she has been blind since birth and has had
four asthma attacks in the past six months. She received
epinephrine (Adrenalin) in the emergency department
and was transferred to the pediatric unit with
aminophylline infusion. When evaluating Amy for
positive effects of the aminophylline treatment, the most
significant finding is:
a. A decrease in mucous production
b. A decrease in wheezing
c. An increase in blood pressure
d. A sleeping child
(Answer: B) Rationale: Aminophylline is a
bronchodilator. As it exerts its effects, wheezing will
decrease. Aminophylline has no effect on mucous
production. A toxic effect of aminophylline is
hypotension. A sleeping child does show evidence that
the drug worked, but this is not the most significant
finding.
51. Bryan, 12-months-old, is hospitalized for a severe
case of croup and has been placed in an oxygen tent.
Today the oxygen order has been reduced from 35% to
25%. His blood gases are normal. Bryan refuses to stay
in the oxygen tent. Attempts to placate him only cause
him to become more upset. The most appropriate action
for the nurse is to:
a. Restrain him in the tent and notify the physician
b. Take him out of the tent and notify the physician
c. Take him out of the tent and let him sit in the
playroom
d. Tell him it will please his mother if he stays in
the tent
(Answer: B) Rationale: The energy exerted by the child
in resisting the oxygen tent is causing increased
32
respiratory effort. The child should be removed from the
tent and closely monitored to be sure that he handles
being in room air. The physician should be notified
because the oxygen content of room air is only 20%,
which is less than that ordered. Restraining him in the
oxygen tent would further increase respiratory effort. It
would be best to leave him in his room where he can be
closely monitored and where the oxygen tent is available
if needed. A proper nursing response would help the
child deal with the treatment by himself and not just do it
to please someone else. The twelve-month-old is
moving into the stage of toddlerhood and the
development of a sense of autonomy.
52. Janie, age 9, has celiac disease, which has been in
good control since it was diagnosed six years ago. She
has now been admitted to the hospital for an emergency
appendectomy. Which preoperative procedure should
the nurse withhold?
a. A cleansing enema
b. Starting an IV
c. Keeping her NPO
d. Obtaining a blood sample for a CBC
(Answer: A) Rationale: Enemas, cathartics, and heat to
the abdomen should all be avoided in appendicitis
because they may cause perforation of the appendix. All
the other measures are appropriate pre-op interventions.
53. Alice, age 8, has celiac disease. She had an
emergency appendectomy. She is progressing well and
is having her first real meal. Which food should the nurse
remove from her tray?
a. Chicken rice soup
b. Crackers
c. Hamburger patty
d. Fresh fruit cup
(Answer: B) Rationale: The prescribed diet for children
with celiac disease is gluten free; crackers contain
gluten, but the other foods do not.
54. Barry K., 12-months-old, had a cleft lip repaired
successfully as an infant. His mother brings him to the
clinic for a checkup and his MMR immunization. While
talking to the nurse, Ms. K. reports that her teenage
babysitter has just come down with rubeola. The most
appropriate plan of treatment for Barry is to:
a. Administer immune serum globulin
b. Administer prophylactic penicillin
c. Vaccinate him now with MMR
d. Allow him to catch measles from the babysitter
in order to develop active immunity
(Answer: A) Rationale: Administration of immune serum
globulin will provide the child wit passive immunity to
prevent a full-blown case of measles or reduce the
severity of symptoms. Penicillin does not prevent or treat
a viral infection. Active immunization with MMR should
be given at a later time. It takes time for active immunity
to develop. It is not appropriate to let the child get a
disease when the disease can be prevented.
55. The nurse is caring for a 12-month-old child who has
a cleft palate. A cleft lip was repaired when he was2
months old. His mother asks the nurse when he will be
ready for a cleft palate repair. The most appropriate
response is that cleft palate repair is usually done:
a. Prior to development of speech
b. When the child is toilet trained
c. When the child is completely weaned from the
bottle and pacifier
d. When a large-holed nipple is ineffective for his
feedings
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
(Answer: A) Rationale: Cleft palate repair should be
done prior to the development of speech. This allows for
the formation of a more normal speech pattern. Being
toilet trained has no relation to cleft palate surgery. The
child does not have to be completely weaned form the
bottle and the pacifier prior to the surgery. However, the
child must be able to drink form a cup because a bottle
may not be used until surgical repair is healed. A large
holed nipple is generally used for a premature infant with
a weak sucking reflex. The child with cleft palate repair is
not allowed to suck until the repair is healed.
56. Bobby, 2-years-old, has had a cleft palate repair. A
priority in the post-op plan of care for Bobby includes
teaching his mother:
a. To resume toilet training after he is up and
around
b. To use a cup or wide bowl spoon for feeding
c. That he will be more prone to respiratory
infections now that his airway is smaller
d. That no further treatment will be needed until his
adult teeth come in at age 6
(Answer: B) Rationale: Care must be taken to not put
anything in the mouth that could damage the suture line.
Toilet training has no relationship to the surgery done.
The child may have regressed in toilet training since the
surgery but may begin again whenever he seems
interested. Now that the repair has been done he should
experience fewer respiratory infections. Additional
stages of treatment may need to be done prior to age 6.
57. Tyrone, age 4 years, has just been diagnosed as
having nephrotic syndrome. His potential for impairment
of skin integrity is related to:
a. Joint inflammation
b. Drug therapy
c. Edema
d. Generalized body rash
(Answer: C) Rationale: A child with nephrotic syndrome
will have massive edema. A child with edema is prone to
skin breakdown. Joint inflammation and generalized
body rash are not usually problems in the child with
nephrotic syndrome. Drug therapy is usually steroids
and diuretics, neither of which is related to impairment of
skin integrity.
58. Walter is 20 months old and admitted to the hospital
with a diagnosis of cryptorchidism. Surgical correction is
performed at this time to prevent:
a. Difficulty in urinating
b. Sterility
c. Herniation
d. Peritonitis
(Answer: B) Rationale: if the testes remain in the
abdomen beyond the age of 5, damage resulting from
exposure to internal body temperature can result in
sterility.
59. Charlie Urich, 3 days old, is diagnosed with
Hypospadias. His parents are very upset and have been
willing listeners as the nurse has explained this problem
to them. The nurse explained that in Hypospadias, the
physical problem is primarily:
a. Ambiguous genitalia
b. Urinary incontinence
c. Ventral curvature of the penis
d. Altered location of the urethral meatus
(Answer: D) Rationale: In Hypospadias, the urethral
opening may be anywhere along the underside of the
penis. This dislocation may be accompanied by genital
edema and fibrous penile dislocation, which may make
33
sexual identification difficult. If uncorrected, the boy will
have problems controlling his urinary stream when he
has outgrown diapers.
60. The parents of a newborn who has Hypospadias ask
about surgical repair. They are told that the preferred
time to schedule surgical repair of Hypospadias is when
the boy is:
a. 9 months old
b. 5 years old
c. 12 years old
d. 17 years old
(Answer: A) Rationale: Most surgical repairs are
scheduled for the child between 6 and 18 months of age.
If left until later, body image problems and
mutilation/castration anxieties may occur.
61. The parents of a baby boy who was born with
Hypospadias want to know about the surgical repair. The
nurse tells them that they will be able to evaluate the
success of Hypospadias surgery by:
a. The cosmetic appearance of the penis
b. Maintaining stable blood pressure in the child
c. Observing a straight stream when he voids
d. His ability to void without discomfort
(Answer: C) Rationale: Observing the child void in a
straight stream while standing is the expected successful
outcome of Hypospadias repair. The penis may be
swollen and discolored after surgery and voiding may be
uncomfortable initially. Having a stable blood pressure is
always important, but its presence does not indicate
successful surgical repair of Hypospadias.
62. Doug, age 3, has a fractured femur and is in Bryant’s
traction. To evaluate correct application of the traction
the nurse should note that:
a. Doug is being continuously and gradually pulled
toward bottom of bed
b. Doug’s buttocks are raised slightly
c. Doug’s leg is at a 45 angle to the bed
d. Doug can move the unaffected leg freely
(Answer: B) Rationale: In Bryant’s traction both legs are
in traction at a 90 angle and the buttocks are raised off
the mattress. The child’s buttocks are raised off the
mattress. The child’s weight provides the
countertraction; he should not be pulled down toward the
bottom of the bed.
63. Ethel, age 14, is in a hip spica cast. To turn her
correctly, the nurse should:
a. Use the cross bar
b. Turn her upper body first, then turn the lower
body
c. Log roll her
d. Tell her to pull on the trapeze and sit p to help in
turning
(Answer: C) Rationale: The client in a hip spica cast
should be turned as a unit. The stabilizing bar should not
be handled.
64. A routine physical examination on 2-day-old Melissa
Carter uncovered evidence of congenital dislocation, or
dysplasia, of the right hip. When assessing Melissa, a
sign of one-sided hip displacement is:
a. An unusually narrow perineum
b. Pain where her leg is abducted
c. Symmetrical skin folds near her buttocks and
thigh
d. Asymmetrical skin folds over the buttocks and
thigh
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
(Answer: D) Rationale: Displacement of the hip on one
side causes asymmetry of skin folds. The baby will not
have pain when her leg is abducted, and skin folds near
he buttocks and thighs will not be symmetrical.
65. An infant is being treated for congenital hip dysplasia
with a Pavlik harness. The baby’s mother asks if she can
remove the harness if it becomes soiled. The best
response for the nurse to make is:
a. No, the harness may not be removed
b. No, she will only be wearing it a few days
c. Yes, just long enough to clean the area
d. Yes, just overnight while she is sleeping
(Answer: A) Rationale: The harness is not to be removed
until the hip is stable with 90 degrees of flexion and x-ray
confirmation. This usually occurs after about three
weeks in a Pavlik harness. No, she cannot remove it, but
it will be in place about three weeks until the hip is
stable.
66. A 10-year-old Jamie takes aspirin QID for Still’s
disease (juvenile rheumatoid arthritis). What symptoms
would her mother observe that would be indicative of
aspirin toxicity?
a. Hypothermia
b. Hypoventilation
c. Decreased hearing acuity
d. Increased urinary output
(Answer: C) Rationale: Tinnitus or ringing in the ears is a
side effect of aspirin therapy. Hypothermia,
hypoventilation, and increased urinary output are not
signs of aspirin toxicity. In salicylate poisoning, the child
will have hyperthermia, hyperventilation to compensate
for metabolic acidosis and may develop renal failure.
67. Jenny, age 8, is newly diagnosed with diabetes
mellitus. Which of the following symptoms is different
from what you would expect to find in maturity onset
(Type II) diabetes?
a. Increased appetite
b. Increased thirst
c. Increased urination
d. Weight loss
(Answer: D) Rationale: Weight loss is associated with
juvenile diabetes, whereas weight gain develops in
maturity-onset diabetes. The other three signs appear in
both forms of the disease.
68. Jane is 7 years old and newly diagnosed with
diabetes mellitus. She had an injection of regular and
NPH insulin at 7:30 A.M. At 3:10 P.M. she complains
that she does not feel well. She is pale, perspiring, and
trembling. The nurse should:
a. Tell her to lie down and wait for the dinner trays
to arrive
b. Ask her to give a urine specimen and test it for
sugar and acetone
c. Give her a carbohydrate snack
d. Administer the afternoon dose of regular insulin
(Answer: C) Rationale: She probably is having a
hypoglycemic reaction form the NPH having a
hypoglycemic reaction from the NPH insulin and needs
an afternoon snack.
69. A 10-year-old with diabetes mellitus is learning how
to administer her insulin. She asks the nurse why she
cannot take pills like her grandmother who also has
diabetes. The best response for the nurse to make is:
a. How long has your grandmother been taking
oral medication?
34
 b. You’ll be able to stop taking insulin once you
stop growing
c. You have a different kind of diabetes and you
will need to take insulin throughout your life
d. You’ll be able to switch to pills when you reach
your grandmother’s age
(Answer: C) Rationale: Juvenile diabetics need lifetime
insulin. She will never be able to switch to oral
hypoglycemics.
70. A 10-year-old is being prepared for a bone marrow
transplant. The nurse can assess how well he
understands this treatment when he says:
a. I’ll be much better after this blood goes to my
bones
b. I won’t feel too good until my body makes
healthy cells
c. This will help all of the medicine they give me to
work better
d. You won’t have to wear a mask and gown after
my transplant
(Answer: B) Rationale: The goal of a bone marrow
transplant is to have the donor cells produce functioning
blood cells for the client. In a bone marrow transplant,
blood is not transfused into the client. Instead bone
marrow is given to the person in the hopes that it will
begin producing normal, healthy blood cells. A bone
marrow transplant is not done to increase the
effectiveness of medication therapy. A mask and gown
will still be worn until the clients begin to produce normal
white blood cells.
71. Susan, age 4, has leukemia. Her mother
understands the white count involvement in this disease
but doesn’t understand why her child has bruises and
anemia. The nurse explains that:
a. All blood cells are made in the bone marrow and
therefore all types will be affected
b. The anemia is because her child hasn’t been
eating well; the bruises are from the multiple
needle sticks
c. They are related to inactivity
d. This is indicative that the end is near
(Answer: A) Rationale: In leukemia, bone marrow is
replaced by blast cells, resulting in decreased white
cells, red cells, and platelets. The bruises are due to the
child’s decreased platelet count.
72. A 14-year-old Louise has had an exacerbation of
acute lymphocytic leukemia. The primary effect of
leukemia on the bone marrow is:
a. Crowding out of normal bone marrow cells
b. Proliferation of cells producing blood
components
c. A selective reduction in number of neutrophils
d. Leukopenia, thrombocytopenia, and anemia
(Answer: A) Rationale: Since leukemia cells are capable
of an increased rate of production and a long cell life,
they crowd out all of the normal bone marrow cells. Cells
producing blood components are then unable to
reproduce. There is no selective reduction, although the
neutrophils, too, may be crowded out in nonmylocytic
leukemias. Leuko0enia is an absolute decrease in the
number of white blood cells in the peripheral circulation;
in leukemia, the white blood cells count rises.
73. A 14-year-old girl has acute lymphocytic leukemia
and is admitted. She is terminally ill. An appropriate
nursing action would be to:
St. Louis Review Center Inc. – BUTUAN CITY; Telephone No. (085) 342 – 2339
a. Leave her alone as much as possible and
whisper when in her room in order not to disturb
her:
b. Assist her in giving away her possessions to
friends and family
c. Encourage Louise’s parents to explain to her 5-
year-old sister that Louise will asleep for a long
time
d. Reduce emotional stress by not having Louise’s
parents/family participate in her care
(Answer: B) Rationale: Adolescents may want to give
away their belongings. The other interventions are all
inappropriate and may increase Louise’s fears and
anxiety.
74. Jack is 10-years-old and is receiving cranial
irradiation for a brain tumor. He has developed alopecia.
Which of the following is an appropriate nursing
intervention?
a. Have Jack identify famous movie stars and
sports heroes who are bald
b. Assure Jack that his hair will grow in before he
leaves the hospital
c. Wrap a bandage around his head
d. Help him select a variety of hats
(Answer: D) Rationale: Selecting hats to cover his head
will help Jack deal with the change in his body image.
The other suggestions are all inappropriate.
POSTTEST
01. A mother asks the pediatric nurse about what she
should begin to feed her 6-month-old infant. The correct
response is:
a. Egg whites are the least allergenic food to be
introduce into the baby’s diet
b. Rice cereal is the first solid introduced that is
least allergenic of the cereals
c. Formula is the only source of nutrition given for
the first year
d. Fruits and vegetables are good sources of iron
(Answer: B) Rationale: Introduction of solid food is
recommended at age 4 to 6 months, when the
gastrointestinal system has matured sufficiently to
handle complex nutrients. The suck reflex and tongue-
thrust reflex diminish at 4 months of age. Rice cereal is
the first solid food because it is a rich source of iron and
rarely induces allergic reactions. Fruits and vegetables,
good sources of vitamins and fiber, are introduced after
cereal, one at a time to determine allergic reactions. Egg
whites are highly allergenic.
02. A 1-year-old male child is scheduled for a routine
exam at the pediatric clinic. The child’s birth weight was
8 lbs, 2 oz. The child now weights 18 lbs, 4 oz. The
nurse knows that this weight is:
a. Below the expected weight
b. Appropriate for the child’s age
c. Above the expected weight
d. Individualized and thus unpredictable
(Answer: A) Rationale: The first year of life is one rapid
growth. The birth weight usually doubles by 6 months
and triples by the end of eth first year. The other choices
are incorrect.
03. The nurse provides anticipatory guidance to parents
of a 3-year-old child. Instructions should include:
35
 a. To restrain the child in the car seat facing rear in
the back seat of the car
b. The use of syrup of ipecac for accidental
poisonings
c. Drug and alcohol education
d. The proper use of sports equipment
(Answer: B) Rationale: Nurses are instrumental in
teaching parents how to make the toddler’s environment
safe by providing instructions about keeping syrup of
ipecac available, having the Poison Control Center
number close to the phone, using child-resistant
containers and cupboard safety closures, and keeping
medicines and other poisonous materials locked away.
Infants are to be restrained in rear-facing car seat,
school-age children should be taught the proper use of
sports equipment, and adolescents should be provided
education regarding drug and alcohol abuse.
04. A school nurse prepares a lecture on puberty for 5 th
and 6th grade girls. She asks the group, “What is the first
sign of puberty?” A student correctly replies:
a. “The appearance of breast buds.”
b. “An increase in energy and appetite.”
c. “The occurrence of the first menarche.”
d. “Appearance of body odor.”
(Answer: A) Rationale: Puberty is a process that brings
about the development of secondary sex characteristics,
which begin with the appearance of breast buds at 9 to
11 years followed by the growth of pubic hair. Menarche
follows approximately 1 year later. Body odor may result
later because of an increase in secretions from the
apocrine glands.
05. The mother discusses with the nurse that her toddler
asks every night for a bedtime story. The mother asks
why the child does this. The nurse would explain that
this behavior demonstrates:
a. Ritualism
b. Object permanence
c. Dependency
d. Conservation
(Answer: A) Rationale: The toddler insists on sameness
(such as a nightly bedtime story). Ritualism allows the
toddler to have a sense of control and to feel more
secure and confident. The child may experience distress
if this routine is not followed. Object permanence is
when the infant develops an awareness that objects
continue to exist when they are out of sight. Dependency
is the need for a caregiver (parent) to provide total care
for another (infant). The school-age child masters the
concept of conservation; learns that certain properties of
objects do not change simply because their form or
appearance has changed.
06. Whenever the parents of a 10-month-old leave their
hospitalized child for short periods, he begins to cry and
scream. The nurse explains that this behavior
demonstrates that the child:
a. Needs to remain with his parents at all times
b. Is experiencing separation anxiety
c. Is experiencing discomfort
d. Is extremely spoiled
(Answer: B) Rationale: Infants and toddlers between the
ages of 6 months and 30 months experience separation
anxiety. There are three stages of separation anxiety.
The child who demonstrates crying and rejecting anyone
other than the parent is in protest, the first stage of
separation anxiety. This behavior does not exhibit
spoiling or any indication of discomfort. The second
stage is despair. The child expresses hopelessness,
appears quiet, and is withdrawn. The third stage is
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detachment. The child becomes interested in the
environment, especially the caregivers. If the parents
return, the child ignores them.
07. A teenager refuses to wear the clothes his mother
bought for him. He states he wants to look like the other
kids at school and wear clothes like they wear. The
nurse explains this behavior is an example of teenage
rebellion related to internal conflicts of:
a. Autonomy vs. shame and doubt
b. Trust vs. mistrust
c. Identity vs. role confusion
d. Initiative vs. inferiority
(Answer: C) Rationale: Erikson’s theory of psychosocial
development states that the child is faced with conflicts
that need to be resolved. Erickson identifies stages of
personality development. Identity vs. role confusion (12
to 19 years) is a period when adolescents search for
answers regarding their future. During this time, the child
rejects the identity presented by his parents and
attempts to create his own identity. Identity is often
based on peers. Positive outcomes result in optimism
and confidence. Negative outcomes result in sense of
purposelessness or deviance.
08. In providing her 8-month-old child’s medical history,
the mother states the child has received on MMR
vaccine. The nurse taking the history should:
a. Ask the mother if the child has received the
MMR booster
b. Plan to administer the MMR booster
c. Explain that one MMR vaccine is all that is
required
d. Plan to administer another MMR vaccine after
the child is 1 year old
(Answer: D) Rationale: This mother may have been
mistaken about the vaccine. Maternal antibodies
interfere with the vaccine when it is given before 12
months of age. Even if the child has had the vaccine, it
will need to be repeated. The first measles-mumps-
rubella (MMR) should be administered to the child
between the ages 12 to 15 months. The second is given
at age 4 to 6 years or 11 to 12 years. Because of
outbreaks of measles in preschoolers, school-age
children, and college students in the 1980s, a second
dose was added to there recommended childhood
immunization schedule. The MMR is a vaccine that is
not given to infants younger than 12 months old.
09. The mother of a 5-year-old expresses concern about
her child who believes that “Grandma is still alive” 3
months after the grandmother’s death. The nurse
explains that:
a. Magical thinking often accounts for a
preschooler who believes that dead people will
come back
b. There is a need for psychological counseling for
this child and family
c. This is a form of regression exhibited by the
preschooler
d. The child is in denial regarding Grandma’s death
(Answer: A) Rationale: The preschooler believes that
death is reversible. Their magical thinking and
egocentricity often results in their belief that the
deceased will come back to life. Preschoolers also often
will blame themselves for the death of another.
10. Hospitalization of a child results in disturbance of the
dynamics in family life. The most appropriate nursing
diagnosis is:
a. Diversional activity deficit related to separations
36
 from siblings and peers
b. Sleep pattern disturbance related to unfamiliar
surroundings
c. Altered family processes related to
hospitalization
d. Ineffective individual coping related to
procedures
(Answer: C) Rationale: Identification of nursing
diagnoses that apply to the specific problem(s) of the
child and family is an essential step of the nursing
process. Family-centered care addresses the needs of
the family members, including the child’s siblings. The
primary goals are to maintain the relationship with the
child and siblings during the period of separation while
hospitalized and avoid boredom and distress for the
hospitalized child.
11. When using the otoscope to examine the ears of a 2-
year-old child, the nurse should:
a. Pull the pinna up and back
b. Pull the pinna down and back
c. Hold the pinna gently but firmly in its normal
position
d. Hold the pinna against the skull
(Answer: B) Rationale: The ear canal in infants and
young children is shorter, wider, and more horizontally
positioned than in older children. To adequately examine
the tympanic membrane in young children the pinna
must be pulled back and down.
12. To assess the height of an 18-month-old child who is
brought to the clinic for routine examination, the nurse
should:
a. Measure arm span to estimate adult height
b. Use a tape measure
c. Use a horizontal measuring board
d. Have the child stand on an upright scale and
use the measuring arm
(Answer: C) Rationale: Children younger than 2 or 3
should be measured lying down, preferably on a
horizontal measuring board, to get an accurate
assessment of height. A tape measure would be used to
measure head circumference. An arm-span measure is
not an appropriate estimation of adult height.
13. At what age is it appropriate to change the sequence
of the examination of the child from that of chest and
thorax first to head-to-toe?
a. Infant
b. Toddler
c. Preschool child
d. Schoolage child
(Answer: D) Rationale: The Schoolage years are the first
time a child is able to reliably cooperate with the
examiner and not squirm, talk, or otherwise interrupt the
exam. In younger children, it is essential to begin with
the chest and thorax because the child needs to be quiet
and at rest.
14. The best description of a nursing diagnosis is:
a. A process used to evaluate the etiology of a
disease
b. A nursing judgment about the health of an
individual
c. A problem-oriented description of an actual or
potential health problem
d. An efficient basis for communicating client data
among nurses
(Answer: C) Rationale: A nursing diagnosis is a
statement of an actual or potential problem that can be
resolved or changed by nursing interventions. It involves
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the use of common labels established by NANDA.
Nursing diagnoses are based on data collected by the
nurse but are not related to disease etiology or
judgments of the overall health status of a client.
15. Screening for strabismus and amblyopia should be
part of the physical assessment of which children?
a. All children under 18
b. Infants
c. Preschool children
d. Schoolage children
(Answer: C) Rationale: Strabismus is detected with the
cover-uncover test that can first be reliably administered
to children over the age of 2. It is important to detect the
problem early to prevent amblyopia. By school age,
vision loss would have occurred.
16. In infants, a positive Babinski reflex is:
a. An indication of a neurological problem
b. Dorsiflexion of the toes
c. Fanning of the toes
d. Withdrawing the foot from the stimulus
(Answer: C) Rationale: A positive Babinski in infants is a
fanning of the toes when a stimulus is applied to the foot
along the lateral edge and across the ball. The response
disappears by about age 2.
17. The review of systems part of the health history is
best described as:
a. The description of the health problem in the
informant’s words
b. The objective data recorded by the nurse
c. The evaluation of the past and present health of
each body system
d. A general statement about the overall health of
the child
(Answer: C) Rationale: The review of systems is a
systematic review of each body system with respect to
past and present health problems. It is designed to
provide a basis for focusing the physical assessment on
problem areas. The statement of the health problem is
the reason for seeking care, sometimes called the chief
complaint. Objective data is gathered during the physical
assessment and from laboratory data.
18. The nurse would perform abdominal percussion to
assess for:
a. Tenderness
b. Inflammation
c. Density of tissues and organs
d. Size and placement of liver
(Answer: C) Rationale: Percussion produces sounds of
varying loudness and pitch depending on the organs and
tissue density. The nurse assesses the liver with
palpation and percussion, but not for placement.
Inflammation is assessed with inspection, and
tenderness is assessed with palpation.
19. When assessing a 4-year-old child with a persistent
cough, the nurse would assess respirations by observing
which muscle group?
a. Thoracic
b. Abdominal
c. Accessory
d. Intercostal
(Answer: B) Rationale: Infants and young children use
the diaphragm and abdominal muscles for respiration, so
the nurse would watch the rise and fall of the abdomen
to count respirations. Use of accessory or intercostal
muscles may be observed in respiratory distress.
37
20. When assessing the fontanels of a 6-week-old infant,
how soon does the nurse expect the posterior fontanel to
close?
a. By 3 months
b. By 6 months
c. By 12 months
d. By 18 months
(Answer: A) Rationale: The posterior fontanel closes by
3 months of age. The anterior fontanel closes by 18
months.
21. A client is to receive eye drops that are ordered to be
given “OS”. The nurse would administer the eye drops:
a. To the left eye
b. To the right eye
c. In both eyes
d. In alternating eyes
(Answer: A) Rationale: OS is the abbreviation for left
eye. OD is the abbreviation for the right eye. OU is the
abbreviation for both eyes.
22. The nurse is caring for a 6-year-old child who just
returned to the day-surgery recovery area from surgery
following a tonsillectomy, adenoidectomy, and bilateral
myringotomy with insertion of tympanostomy tubes.
Which assessment data would indicate that the child is
experiencing active, uncontrolled bleeding at the
operative site?
a. Tachycardia, hypertension, hemoptysis
b. Bradycardia, hypotension, increased swallowing
c. Tachycardia, hypotension, decreased
swallowing
d. Tachycardia, hypotension, increased swallowing
(Answer: D) Rationale: The nurse observes increases
swallowing. Tachycardia and hypotension are late signs
of significant blood loss. The other options are incorrect.
23. The nurse is planning postoperative care for a
pediatric client following tonsillectomy. Nursing
considerations include which of the following?
a. A child’s behavior response to pain is affected
by age and developmental level
b. Recovery from a painful procedure occurs at a
faster rate in children as compared to adults
c. Opioid analgesic use in children is dangerous
because of increased risk of addiction and
respiratory depression
d. The immaturity of the nervous system in young
children provides them with an increased pain
threshold
(Answer: A) Rationale: Option 1 is the only true
statement. Infants are less able to communicate their
feelings than an older child and usually demonstrate
restlessness and crying behaviors. Adolescents are able
to describe their pain sensations.
24. The nurse is beginning an otoscopic examination of
the ear of a 2-year-old child. The child cries, kicks, and
pulls away from the nurse. How should the nurse
proceed?
a. Explain to the child why the ear must be
examined
b. Postpone the examination until the next clinic
visit in one year
c. State, “I though you were going to be grown up
for me today.”
d. Get assistance to restrain the child to proceed
with the exam
(Answer: D) Rationale: Uncooperative pediatric clients
may need to be restrained long enough to accomplish
the assessment or procedure that is necessary. Other
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options are incorrect.
25. During a day-surgery hospitalization experience for
tonsillectomy, a 3-year-old child will most likely be fearful
of:
a. Intrusive procedures
b. Perceived abandonment
c. Premature death
d. Unfamiliar caregivers
(Answer: A) Rationale: One of the greatest fears of
preschoolers is fear of mutilation. Other options are not
developmentally appropriate responses for a
preschooler.
26. The nurse is performing an assessment of a 14-
month-old toddler admitted to the day-surgery unit for
bilateral myringotomy and placement of tympanostomy
tubes. How should the nurse obtain the child’s
temperature?
a. The nurse should use a tympanic thermometer
with disposable speculum
b. The nurse should use an oral thermometer with
disposable plastic sheath
c. The nurse should use a rectal thermometer with
disposable plastic sheath
d. The nurse should use a temperature strip placed
on the child’s forehead
(Answer: A) Rationale: The tympanic method is
preferred. It is quick, accurate, and convenient. Oral
temperature can be obtained on a cooperative child
aged 3 and older. A rectal temperature is obtained as a
last resort, when other methods are not possible.
27. Which of the following care measures is indicated in
teaching home care of a child with bilateral bacterial
conjunctivitis?
a. Use of warm, moist, disposable compresses to
remove crusting
b. Use of oral antihistamine medication to relieve
eye itching
c. Use of ophthalmic corticosteroids to decrease
inflammatory response
d. Use of topical anesthetics applied to relieve
discomfort
(Answer: A) Rationale: Crusting of dried exudates is
common with bacterial conjunctivitis. Other options are
not indicated in the management of bacterial
conjunctivitis.
28. The parent of an infant diagnosed with viral
nasapharyngitis should be taught to notify the health
care provider:
a. Of increased fussiness
b. If the infant develops a cough
c. Of temperature above 98.6F
d. If the infant develops signs of ear infection
(Answer: D) Rationale: Options 1 to 3 are expected
symptoms of viral pharyngitis in infants. Symptoms of
ear infection should be reported to the health care
provider.
29. Decongestant nasal drops are prescribed for an
infant with nasapharyngitis. Instructions for administering
the drops include which one of the following:
a. Do not use the drops or dropper for any other
family member
b. Save any remaining medication for the next time
the child is congested
c. Administer the drops frequently until the nasal
congestion subsides
d. Insert the dropper tip as far into the infant’s nose
38
 as is possible
(Answer: A) Rationale: Eliminating contact or sharing of
items with the infected person can reduce the potential
spread of infection to other family members. The other
options are incorrect.
30. The nurse teaches the family of a toddler with
streptococcal pharyngitis the importance of finishing the
full course of oral antibiotic therapy. The nurse explains
that a potential complication of untreated streptococcal
infection is:
a. Otitis media
b. Diabetes insipidus
c. Nephritic syndrome
d. Acute rheumatic fever
(Answer: D) Rationale: Rheumatic fever can follow an
infection of certain strains of group A betahemolytic
streptococci. Other options are incorrect.
31. The mother of an infant diagnosed with bronchiolitis
asks the nurse what causes this disease. The nurse’s
response would be based on the knowledge that the
majority of infections that cause bronchiolitis are a result
of:
a. Ribavirin
b. Mycoplasma pneumoniae
c. Respiratory syncytial virus (RSV)
d. Hemophilus influezae
(Answer: C) Rationale: At least one-half of all cases of
bronchiolitis are attributed to RSV. The other responses
are incorrect.
32. A child is brought to the Emergency Department with
suspected epiglottitis. Which nursing intervention would
be considered unsafe?
a. Allowing the child to remain in the position of
choice
b. Placing intubation equipment at the bedside
c. Encouraging parents to comfort the child
d. Examining the throat
(Answer: D) Rationale: Any manipulation of the tongue
or throat may stimulate the gag reflex and cause
complete obstruction. Emergency intubation equipment
should be readily available before any examination of
the throat is attempted.
33. An 18-month-old child is seen in the Emergency
Department with respiratory distress and is admitted with
a diagnosis of pneumonia. Following the initial workup,
the baby is still short of breath but is rubbing his eyes as
if he is sleepy. The mother wants to lay the baby down
for his nap. The infant refuses to lie down. The nurse
would suggest:
a. Rocking the baby until he is asleep and then lay
him down
b. The mother hold him in her arms while he sleeps
c. The mother allow the baby to sleep in an upright
position
d. A sleeping pill to help the baby rest
(Answer: C) Rationale: The child’s respiratory distress
makes lying down difficult. The child will breath more
easily in semi-to high-Fowler’s position.
34. Which statement by an 8-year-old child with asthma
indicates that she understands the use of a peak
expiratory flow meter?
a. “My peak flow meter can tell me if an asthma
episode might be coming, even though I might
still be feeling okay.”
b. “When I do my peak flow, it works best if I do
three breaths without pausing in between
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breaths.”
c. “I always start with the meter reading about
halfway up. That way I don’t waste any breath.”
d. “If I use my peak flow meter every day, I will not
have an asthma attack.”
(Answer: A) Rationale: Peak expiratory flow readings
over time indicate the child’s respiratory ability when she
is well. Readings of 50 percent below “personal best”
indicate an asthma episode is imminent. It does not
prevent an attack.
35. A child with cystic fibrosis is hospitalized for a
respiratory infection. Which documentation in the chart
would indicate the need for counseling regarding
nutrition and gastrointestinal complications?
a. Frothy, foul-smelling stools
b. Weight unchanged from yesterday
c. Consumed 80 percent of breakfast
d. Eats three snacks every day
(Answer: A) Rationale: Frothy, foul-smelling stools
reflects malabsorption and indicate that pancreatic
enzymes are not being consumed or dosages may need
adjustment. Maintenance of weight and consuming
meals and snacks are positive nutrition goals for children
with cystic fibrosis.
36. An adolescent was diagnosed with cystic fibrosis as
an infant. At this time, the adolescent will need additional
teaching related to:
a. Obtaining a sweat chloride test
b. The effect of pancreatic enzymes on the sex
hormones
c. Weight reduction diet
d. Reproductive ability
(Answer: D) Rationale: The developmental task of
adolescence is to set future goals, including marriage
and family. Men are usually sterile, and women may
have decreased fertility as thick cervical mucus
interferes with mobility of sperm. The difference between
sterility and impotence should also be addressed.
37. The parents of a child with cystic fibrosis inform the
nurse that they will be unable to perform postural
drainage at home because their bed does not recline like
the hospital bed. The nurse’s response is based on an
understanding that:
a. Postural drainage is essential to mobilize
secretions in the airways so they can be
coughed out
b. Postural drainage is not necessary as long as
the child takes his pulmozyme to decrease the
viscosity of the mucus
c. Postural drainage does not influence the
pulmonary status of a child with cystic fibrosis
d. The parents can be referred to the Cystic
Fibrosis Foundation for a flexible bed
(Answer: A) Rationale: The removal of thick, pulmonary
secretions is critical to the maintenance of adequate lung
function and prevention of infection. Daily chest
physiotherapy, including postural drainage, is required
and must be consistently performed. Playground
activities such as monkey bars, trapeze bar,
somersaults, and headstands can accomplish the
purposes of postural drainage.
38. An 11-month-old child is being discharged home for
the first time after being diagnosed with
bronchopulmonary dysplasia (BPD). She will require
home oxygen therapy. Which statement by the mother
indicates that discharge teaching is incomplete?
a. “We will not allow any smoking at our home.”
39
 b. “We have several fire extinguishers, and we
know how to use them.”
c. “Her brother will blow out the birthday candles at
her party.”
d. “We will return to the hospital if she seems
irritable and won’t play.”
(Answer: C) Rationale: There should be no open flames
when oxygen is in use; oxygen enhances combustion
and is a fire hazard.
39. The nurse is teaching home tracheostomy care to
the parents of a toddler. What information is essential to
include?
a. The importance of changing the tracheostomy
every day
b. How to recognize signs of infection and
obstruction
c. How to remove the tracheostomy so the child
can talk
d. Teaching the child to keep large objects away
from the tube
(Answer: B) Rationale: Accumulating mucopurulent
secretions may provide a medium for bacterial growth or
can obstruct the lumen of the tube. Suctioning is another
risk for introduction of bacteria. Early recognition of signs
of infection is important.
40. A child with a respiratory infection is scheduled to
have a sweat test. The mother asks the purpose of this
diagnostic test. The nurse’s response would be based
on the knowledge that the rest:
a. Determines if the child is dehydrated
b. Assess if the sweat glands are functioning
c. Identifies the infectious organism
d. Establishes a diagnosis of cystic fibrosis
(Answer: D) Rationale: Children with cystic fibrosis have
elevated chloride concentrations of sweat because of the
dysfunction of the exocrine glands.
41. A toddler has been diagnosed with an acyanotic
cardiac defect. Which assessment data would most
likely indicate congestive heart failure?
a. Heart murmur
b. Cardiac volume overload
c. Anuria
d. Excitability
(Answer: B) Rationale: Congestive heart failure may
occur when the amount of blood passing from left to right
side of the heart overloads the pulmonary system.
42. An infant who ahs a congenital heart defect comes
into the clinic with complaints of irritability, pallor, and
increased cyanosis that began quickly over the last 30
minutes. As the nurse assesses the infant, the parent
asks why the child’s color is bluish. The best response
by the nurse is, “Skin color is:
a. Related to the time of day.”
b. Related to brain function.”
c. Related to hemoglobin level and oxygen
saturation.”
d. Unrelated to your child’s condition.”
(Answer: C) Rationale: The hemoglobin molecule carries
oxygen. The oxyhemoglobin gives the skin the pink
color. In the absence of oxyhemoglobin, the skin color
darkens.
43. A client is admitted with a diagnosis of “rule out
rheumatic fever.” Based on Jones Criteria, the nurse
assesses for:
a. Polyarthritis and dental caries
b. Fever, headache, and low red blood cell count
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c. Chorea, muscle weakness, and decreased
erythrocyte sedimentation rate
d. Erythema, polyarthritis, and elevated
antistreptolysin-O (ASO) titer
(Answer: Jones Criteria is a protocol to assist in
identifying rheumatic fever. It consists of major
symptoms, minor symptoms, and supporting evidence.
Erythema, polyarthritis, and elevated ASO titer are
among the major and minor symptoms and supporting
evidence.
44. A toddler with Kawasaki’s disease is ordered to
receive aspirin therapy. Typical administration of aspirin
for Kawasaki’s disease would include which of the
following principles?
a. High doses of aspirin should be given while
fever is high
b. Length of aspirin therapy is related to child’s
response
c. Aspirin dose increases after fever is gone
d. Aspirin dosage is unrelated to platelet count
(Answer: B) Rationale: Aspirin therapy is ordered 80 to
100mg/kg/day until fever drops. Then aspirin is
continued at 10mg/kg/day until platelet count drops.
Aspirin is used as an antipyretic and anti-agglutination
drug.
45. A newborn with possible hypoplastic left heart
disease is to be admitted to the nursing unit. Which drug
should be available for use?
a. Digitoxin (Crystodigin)
b. Prostaglandin E1 (Prostin VR)
c. Morphine
d. Testosterone (Andro)
(Answer: B) Rationale: Prostaglandin E1 prevents
closure of ductus arteriosus and thereby allows for
mixing of oxygenated and unoxygenated blood until
palliative surgery can be done.
46. A 2-year-old child is being discharged home and will
have palliative surgery for tetralogy of Fallot at a later
date. The mother wants to know about how much
physical activity she can allow for the child. The nurse’s
best answer is:
a. “Allow the child to regulate her activity.”
b. “Keep her on complete bedrest.”
c. “Limit her activities to a few hours.”
d. “Keep the child from crying.”
(Answer: A) Rationale: Although a child requiring surgery
for tetralogy of Fallot may have a need for additional
services, such as supplemental oxygen at home, the
child should be able to play and move about in the
environmental needs.
47. After a pediatric client has a cardiac catheterization,
which intervention would have the highest priority in the
immediate postoperative period?
a. Encourage intake of small amounts of fluid
b. Teach the parents signs of congestive heart
failure
c. Monitor the site for signs of infection
d. Apply direct pressure to entry site for 15 minutes
(Answer: D) Rationale: Direct pressure on wound site
helps to form clot and reduce bleeding. Hemorrhage can
be life threatening in the immediate postoperative period.
48. A child is being seen in the ambulatory clinic for a
sore throat diagnosed as caused by group A
betahemolytic streptococcus. The nurse provides care
with the understanding that the risk of developing
rheumatic fever is greatest:
40
 a. Two weeks later
b. Prior to administering an antibiotic
c. Once the child has begun antibiotic therapy
d. With the onset of the strep infection
(Answer: A) Rationale: Rheumatic fever often follows 2
weeks after a streptococcal infection regardless of
treatment.
49. Which evaluation would indicate a toxic dose of
digoxin?
a. Tachycardia and dysrhythmia
b. Headache and diarrhea
c. Bradycardia and nausea and vomiting
d. Tinnitus and nuchal rigidity
(Answer: C) Rationale: Signs of digoxin toxicity include
bradycardia, arrhythmia, nausea, vomiting, anorexia,
dizziness, headache, weakness and fatigue.
50. The nurse is developing a discharge-teaching plan
for the family of a child with Kawasaki’s disease. Which
of the following is the first priority?
a. Teaching parents to administer aspirin and
watch for side effects
b. Recommending the child avoid contact sports
c. Monitoring the child’s temperature and notifying
the doctor if it is over 98.6F
d. Establishing home schooling for 6 months
(Answer: A) Rationale: Aspirin is an anti-inflammatory
and antipyretic. The child may experience bleeding and
G.I. upset as side effects.
51. A 3-month-old infant has been admitted with a
diagnosis of encephalitis. The first nursing priority would
be to assess:
a. Pupillary reaction
b. Level of consciousness
c. Ability to maintain airway
d. Blood glucose level
(Answer: C) Rationale: While all other choices are
important to monitor, the priority in assessing any
critically ill child follows the AABC rule – airway,
breathing, and circulation.
52. The nurse places the young child scheduled for a
lumbar puncture in a side-lying position with head flexed
and knees drawn up to the chest. The mother asks why
the child has to be positioned this way. The nurse
explains the rationale for the positioning is that:
a. Pain is decreased through this comfort measure
b. Injury to the spinal cord is prevented
c. Access to the spinal fluid is facilitated
d. Restraint is needed to prevent unnecessary
movement
(Answer: C) Rationale: This position opens the
intervertebral spaces and allows easier access to spinal
canal. The position does not decrease pain or help to
restrain the child. All lumbar punctures are done below
L4 (the level of the spinal nerves) so injury to the spinal
cord is always avoided.
53. An 18-month-old child is observed having a seizure.
The nurse notes that the child’s jaws are clamped. The
priority nursing responsibility at this time would be:
a. Start oxygen via mask
b. Insert padded tongue blade
c. Restrain child to prevent injury to soft tissue
d. Protect the child from harm from the
environment
(Answer: D) Rationale: Never forcibly restrain a child
during a seizure or insert a padded tongue blade; both
are more likely to add trauma than prevent. Oxygen via
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mask is of little benefit. Overall, the child must be
protected form injury from the environment.
54. The nurse conducts Denver II screenings at a
community center for infants and young children. The
nurse explains that the purpose of these screenings is
to:
a. Reverse degenerative processes that have
occurred
b. Recognize early infection in order to prevent
spread to individuals in close contact with the
child
c. Recognize a disorder early so strategies can be
developed to promote optimum development
d. Measure intelligence and readiness for school
(Answer: C) Rationale: The Denver II is a developmental
screening test. The primary reason for doing
developmental screenings to find children who might be
at risk and refer them for further assessment so that
possible delays can be identified and appropriate early
intervention initiated. The Denver II is not a measure of
intelligence. It has nothing to do with infection control nor
is it an intervention to correct degenerative processes.
55. The nurse is providing client education for a family
whose child has cerebral palsy and is receiving baclofen
epidural therapy to control spasticity. Which of the
following is most important for the nurse to include in the
discussion?
a. The drug acts to inhibit the neurotransmitter
GABA
b. The child should be able to run with normal gait
after insertion of the pump
c. Parents must bring the child back to the clinic on
a regular basis to have more medicine added to
the pump
d. Parents can be taught to regulate the dosage on
a sliding scale
(Answer: C) Rationale: This therapy involves an
implanted pump that must be accessed through the skin
to refill the pump. Parents are not taught to refill the
pump. Baclofen does inhibit the neurotransmitter GABA;
however, it is not the essential data to be shared with the
parents. Promising the parents that the child will be able
to run with normal gait offers false hopes. The implanted
ump’s dosage cannot be changed without special
equipment.
56. A 10-year-old client presents with weakness in legs
and history of the flu. The medical diagnosis is Guillain-
Barre syndrome. It would be imperative that the
physician be informed if the nurse observes:
a. Weak muscle tone in feet
b. Weak muscle tone in legs
c. Increasing hoarseness
d. Tingling in the hands
(Answer: C) Rationale: Gurllain-Barre is an ascending
paralysis. While the child will have increasingly less
muscle tone in extremities, the hoarseness could
indicate involvement in the muscles of respiration.
Serious concern is raised when the respiratory muscles
are affected. Sometimes mechanical ventilation is
indicated. Tingling is a common sign of Guillain-Barre
and not related to respiratory distress.
57. The nurse is providing discharge instructional for a
child who has suffered a head injury within the last four
hours. The nurse will recognize the need for additional
teaching when the mother states:
a. “I will call my doctor immediately if my child
starts vomiting.”
41
 b. “I won’t give my child anything stronger than
Tylenol for headache.”
c. “My child should sleep for at least 8 hours
without arousing after we get home.”
d. “I recognize that continued amnesia about the
injury is not uncommon.”
(Answer: C) Rationale: Discharge instructions will
include the necessity of waking the child to check for
neuro status throughout the night. Vomiting could be a
sign of increasing intracranial pressure and should be
reported. Narcotics are not given after a head injury.
Amnesia for the events surrounding the injury may be
permanent. It is not a sign of increasing intracranial
pressure.
58. The Glasgow Coma Scale is used to measure
neurological functioning. Which of the following criteria
would indicate the lowest level of functioning for an
infant or young child?
a. Confused
b. Irritable, cries
c. Eyes open only to pain
d. No response to painful stimuli
(Answer: D) Rationale: No eye opening, no verbal
response, and no motor response are the lowest criteria
on the scale. Confusion is a criterion applicable only for
the older child and adult but is comparable to “irritable
and cries” for the infant (which is a 4 out of 5 on the
verbal response subscale). “Eyes open only to pain” is
next to the lowest level on the eye-opening category.
59. Upon performing a physical assessment of a 7-
month-old child, the nurse notes an abnormal finding
that could suggest cerebral palsy. The finding suggestive
of cerebral palsy is that the child has:
a. No head lag when pulled to a sitting position
b. No Moro or startle reflex
c. Positive tonic neck reflex
d. Absence of tongue extrusion
(Answer: C) Rationale: The Moro or startle, tongue
extrusion, and tonic neck reflex are all neonatal reflexes
that should have disappeared by this child’s age. Lack of
head lag indicates good motor development. A
developmental delay or the presence of a neonatal reflex
is some of the earliest clues to cerebral palsy.
60. A 4-year-old child is being evaluated for
hydrocephalus. An early indication of hydrocephalus in
this child would be:
a. Bulging fontanels
b. Rapid enlargement of the head
c. Shrill, high-pitched cry
d. Early morning headache
(Answer: D) Rationale: All of the above are symptoms of
increased ICP or hydrocephalus. Head enlargement and
bulging fontanels would not be seen in the child after
closure of the sutures (12 to 18 months). Shrill, high-
pitched cry is a late-stage symptom of children.
Headache and vomiting on arising would be an early
symptom in an older child.
61. The most important nursing activity in managing a
young child diagnosed with urinary tract infection (UTI) is
to:
a. Provide adequate nutrition to prevent
dehydration
b. Prevent enuresis
c. Administer ordered antibiotics on schedule
d. Restrict fluids to provide kidney rest
(Answer: C) Rationale: Urinary tract infections are
ascending in nature; an untreated UTI can lead to acute
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Pyelonephritis with resulting kidney scarring and
damage. Early diagnosis and prompt antimicrobial
therapy will prevent or minimize permanent renal
damage.
62. When reviewing a urinalysis report of a client with
acute glomerulonephritis, the nurse would expect to
note:
a. Decreased creatinine clearance
b. Decreased specific gravity
c. Proteinuria
d. Decreased erythrocyte sedimentation rate (ESR)
(Answer: C) Rationale: Proteinuria (presence of protein
in urine) is a prime manifestation of acute
glomerulonephritis. The other options are inconsistent
with this diagnosis.
63. While a child is receiving prednisone (Deltasone) for
treatment of nephritic syndrome, it is important for the
nurse to assess the child for:
a. Infection
b. Urinary retention
c. Easy bruising
d. Hypoglycemia
(Answer: A) Rationale: Prednisone is synthetic
corticosteroids that depresses the immune response and
increases susceptibility to infection. Steroids mask
infection; therefore, the child must be assessed for
subtle signs and symptoms of illness.
64. Which of the following interventions will help obtain
accurate urinalysis data?
a. Force fluids to 1000mL prior to specimen
collection
b. Cleanse the specimen container with povidon-
iodine (Betadine) prior to collecting the
specimen
c. Allow the urine to cool to room temperature
before taking it to the lab
d. Provide client/parent education for specimen
collection before the specimen is obtained
(Answer: D) Rationale: Specimens collected utilizing
proper technique will minimize contamination of the urine
sample ensuring accurate urinalysis results. It is
unnecessary to force fluids prior to specimen collection.
The specimen container is not cleansed, although the
urinary meatus is. The specimen should be sent to the
lab immediately after collection to prevent urine
degradation.
65. The parents of a child diagnosed with upper urinary
tract infection (UTI) ask the nurse why the child needs a
daily weight. In formulating a response, the nurse
includes that it is important because a daily weight will:
a. Determine if the child’s caloric intake is
adequate
b. Indicate the need for dietary restrictions of
sodium and potassium
c. Keep track of possible loss or gain of fluid
retained in body tissues
d. Track the amount of fluid ingested orally each
day
(Answer: C) Rationale: With infectious or inflammatory
processes of the upper urinary tract, the kidneys’ ability
to filter and reabsorb salt and water is altered, resulting
in edema. Weights can be an easy and effective
measure to determine fluid loads.
66. A child has been diagnosed with acute renal failure
secondary to an infectious organism. The nurse would
question the medical order for:
42
 a. Aqueous penicillin
b. Gentamicin (Garamycin)
c. Antihypertensive
d. Corticosteroids
(Answer: B) Rationale: Gentamicin is an aminoglycoside
antibiotic that is nephrotoxic. Nephrotoxic drugs should
be avoided in a child with acute renal failure. The other
options do not represent drug groups that are particularly
nephrotoxic.
67. The newborn has been diagnosed with
cryptorchidism. The physician has ordered human
chorionic gonadotropin (HCG) to be administered to the
baby. The mother asks the nurse why the baby is
receiving this drug. The nurse’s best explanation would
be the drug will:
a. Maintain an adequate temperature around the
testes
b. Prevent infections in the undescended testes
c. Prevent the development of cancer
d. Promote descent of the testes
(Answer: D) Rationale: HCG is given to induce the
descent of testes if testes have not descended during
the first year of life. The other reasons listed are
incorrect rationales.
68. The nurse admits children with the following
diseases to the unit. Which disease places the child at
risk for the development of acute renal failure (ARF)?
a. Leukemia
b. Cryptorchidism
c. Nephrotic syndrome
d. Phenylketonuria
(Answer: C) Rationale: Nephrotic syndrome is an
inflammatory reaction in the kidneys. The other diseases
pose minimal risk of developing acute renal failure.
69. A child has recurrent nephritic syndrome. The
mother reports to the nurse that she is overwhelmed with
the care of her child. After the nurse discusses options
with the mother, which statement by the mother
indicates continued coping difficulties?
a. “I joined a support group like you suggested. I
hope it does some good.”
b. “I’m going to ask my mother-in-law to come on a
regular basis to allow m e an afternoon out.”
c. “My husband has agreed to help me manage my
son’s medication.”
d. “We’re going to skip his dietary restrictions one
day a week to allow us both some relaxation.”
(Answer: D) Rationale: The parents must understand the
need for compliance with medical orders to promote the
child’s health. Relaxation should be accomplished
without harming the child.
70. A child returning to the unit after an intravenous
pyelogram (IVP) has an order to drink extra fluids. When
the mother asks the purpose of these fluids, the nurse
responds that increased fluid intake will:
a. Overhydrate the child
b. Increase serum creatinine levels
c. Make up for fluid losses from NPO status before
tests
d. Flush any remaining dye from the urinary tract
(Answer: D) Rationale: The additional fluids will increase
urinary output, causing greater urine volume and more
frequent voiding, thus flushing the dye from the urinary
system. The other options do not describe the correct
rationale for this intervention.
71. A 12-year-old client was just diagnosed with Type 1
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diabetes mellitus. As you are teaching him about his
insulin infections, he asks you why he can’t take the
diabetic pills that his aunt takes. What would be the best
response?
a. “You will be able to take the pills once you reach
adult height.”
b. “You have a different type of diabetes, and the
pill won’t work.”
c. “We have to test you to see if you can take the
diabetic pills.”
d. “You might be able to switch between taking the
pills and insulin.”
(Answer: B) Rationale: Children with Type 1 diabetes
must take insulin because they have a total absence of
secretion of insulin from their pancreas. Clients with
Type 2 diabetes mellitus may produce some insulin so
they can take the oral hypoglycemics.
72. When instructing a client on the best way to check
the control of diabetes, you would say:
a. “Check your rune glucose three times a week.”
b. “Check the glycosolated hemoglobin every 3
months only.”
c. “Check the blood glucose at least twice a day
and the glycosolated hemoglobin every 3
months.”
d. “Don’t check anything as long as you feel well.”
(Answer: C) Rationale: Checking the blood glucose at
least twice a day prevents sustained levels of either high
or low glucose readings. The glycosolated hemoglobin
measures long-term control and is a very important
value.
73. A mother attends the pediatric clinic with her 10-
year-old daughter, who has diabetes. After completing
the diabetic teaching, the nurse evaluates the mother’s
knowledge. Which statement by the mother indicates a
satisfactory understanding of diabetes?
a. “I worry about my daughter maintaining control
since children with diabetes have more
complications than adults do.”
b. “My daughter should drink vanilla milkshakes to
maintain a high caloric intake.”
c. “Complications from diabetes could include
cataracts and kidney stones.”
d. “My child won’t need a midafternoon snack since
she takes a gym class in the afternoon.”
(Answer: A) Rationale: Long-term complications of Type
1 diabetes may include retinopathy, heart disease, renal
failure, and peripheral vascular disease. These
complications can affect children and adults. The longer
the child lives with diabetes, the greater the likelihood of
complications. Exercise increases the utilization of
glucose, thus an afternoon snack would be very
important. Milkshakes contain concentrated
carbohydrates that should be avoided.
74. Considering a child’s developmental level in diabetic
care is essential. The nurse should include which
information in teaching the parents of a recently
diagnosed toddler with diabetes?
a. Allow the toddler to assist with the daily insulin
injections
b. Prepare meat, vegetables, and potatoes for
each dinner. The toddler cannot be allowed any
choices in food selection
c. Test the toddler’s blood glucose every time he
goes outside to play
d. Allow the toddler to assist with cleaning off his
finger before blood glucose monitoring
(The toddler needs to feel some control. Cleaning off his
fingers with alcohol, under supervision, will allow some
43
control. Another possibility to promote the toddler’s
sense of control would be to allow the toddler to choose
food selections from options offered.
75. A 2-month-old infant arrives at the pediatric clinic.
Upon assessment, the baby exhibits the following
characteristics. Which characteristics would be related to
the diagnosis of congenital hypothyroidism?
a. Open fontanels
b. Protruding tongue
c. Tachycardia
d. Hypertonia
(Answer: B) Rationale: Most babies with congenital
hypothyroidism exhibit bradycardia, protruding tongue,
and hypotonia. Open fontanels are normal for a 2-
month-old infant.
76. A 10-year-old girl comes to the office of the school
nurse after recess. This is the child’s first day back in
school after hospitalization, where she was diagnosed
with diabetes. The child reports she took the dose of
insulin as instructed and that it was the same as she
took while hospitalized. The nurse notices that she is
nervous with hand tremors present. She is pale, sweaty,
and complaining of sleepiness. The school nurse would
suspect:
a. Exercise-induced hypoglycemia
b. Hyperglycemia caused by increased intake at
lunch
c. Ketoacidosis caused by an infection
d. The child is avoiding returning to class
(Answer: A) Rationale: Exercise makes the body more
sensitive to insulin, thus metabolizing the glucose faster.
While hospitalized, the child was less active. Now that
the child has returned to normal activity, the insulin dose
is too high or more carbohydrate is required in the diet.
77. After being diagnosed with Grave’s disease, a
teenager begins taking propylthiouracil (PTU) for
treatment of the disease. What symptom would indicate
that the dose might be too high?
a. Weight loss
b. Polyphagia
c. Lethargy
d. Difficulty with school work
(Answer: C) Rationale: Lethargy may indicate an
overdose of the drug, causing the child to exhibit signs of
hypothyroidism. The other signs indicate
hyperthyroidism.
78. A 13-year-old male client is being evaluated for
delayed puberty. He has had an examination with a
pediatric endocrinologist who states that the child ahs a
constitutional delay. What type of follow-up counseling
would you offer this client?
a. “All of your hormone levels are normal, so no
medication is needed at this time. If you want to
talk about it, I would be happy to discuss it with
you.”
b. “I am worried about your stature. I think you
should get another opinion.”
c. “Your father’s stature doesn’t matter. We just
look at your height.”
d. “If you want testosterone shots, I will arrange for
them to be given.”
(Answer: A) Rationale: An adolescent client with delayed
puberty may need to talk about issues of low self-
esteem. If he has a constitutional delay, puberty will
usually follow with time. Hormone therapy is not given
until after the age of 14.
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79. A child demonstrates a sudden onset of
thyrotoxicosis, exhibited by irritability and restlessness
with accompanying hypertension and tachycardia.
Besides antithyroid therapy, what other drug therapy
does the nurse prepare to administer?
a. Antacids
b. Beta-andrenergic blocker
c. Muscle relaxants
d. Cardiac glycoside
(Answer: B) Rationale: A beta-adrenergic blocking agent
provides relief from adrenergic hyper responsiveness. It
is usually needed for 2 to 3 weeks along with anti-thyroid
hormone therapy.
80. Four newborns have had blood drawn for the Guthrie
test for phenylketonuria. The nurse would question the
results of the baby:
a. Whose test is performed at 48 hours of age
b. Who was breast-fed for the 24 hours before the
test
c. Fed glucose water followed by formula for 30
hours
d. Tested immediately after birth
(Answer: D) Rationale: The screening is done only after
an adequate amount of protein has been ingested.
Breast milk and formula meet the requirements. The
testing is usually done at 48 hours of age.
81. Parents of an unborn infant have just learned that,
based on ultrasound, their infant has clubfoot. They ask
the nurse how clubfoot is treated. Which of the following
treatments should the nurse discuss with the parents?
a. Weekly cast changes with manipulation
b. Probable surgery on the affected limb
c. Abduction device to keep the hip in full
abduction
d. Use of a Denis Browne splint to achieve
correction
(Answer: A) Rationale: The initial treatment for clubfoot
begins immediately or shortly after birth and consists of
weekly cast changes and manipulation. Surgery is
completed only if nonsurgical intervention of serial
casting is not effective. A Denis Browne splint may be
used to maintain correction once it is achieved.
Abduction devices are used for hip conditions.
82. An infant is placed in a Pavlik harness for
developmental dysplasia of the hi0p. Which of the
following statements made by a parent indicates correct
knowledge of the care of this infant?
a. “The straps of the harness should be placed
nest to the skin.”
b. “The harness should be worn for 6 hours a day.”
c. “It will take a long time for my child to walk and
craw.”
d. “I can move my child around on a large
skateboard.”
(Answer: D) Rationale: A child in an abduction splint
needs to be kept mobile, which can be done with the use
of a wagon, large skateboard, or cart. Though diapers
should be placed over the straps of a Pavlik harness, a t-
shirt should be worn under the straps of the harness.
The harness should be worn for 23 hours a day. The
child quickly “catches up” once the device is no longer
worn if developmental milestones are delayed because
of the abduction device.
83. Which of the following nursing diagnoses takes
highest priority for the child hospitalized with
osteogenesis imperfecta?
a. Impaired skin integrity related to cast
44
 b. Pain related to fractures
c. Risk for injury related to disease state
d. Body image disturbance related to short stature
(Answer: C) Rationale: Because of their very fragile
bones, children with OI experience countless fractures,
and the prevention of injury takes highest priority in this
child’s care.
84. Which of the following would not be consistent with
common assessment findings in a child diagnosed with
an acute onset of Legg-Calve-Perthes (LCP) disease?
a. Swelling and redness of the involved joint(s)
b. Stiffness in the morning or after rest
c. Insidious limp after activities
d. Referred pain to the knee
(Answer: A) Rationale: Swelling and redness of involved
joints is a symptom found in juvenile arthritis, not LCP
disease. All of the other symptoms listed are consistent
with this diagnosis.
85. A 12-year-old male is admitted to the adolescent unit
with a diagnosis of slipped capitol femoral epiphysis.
Which of the following activities should not be allowed
prior to surgical correction?
a. Ambulation with crutches, avoid bearing weight
on the affected leg
b. Sitting in a wheelchair
c. Moving on a stretcher
d. Maintaining bedrest
(Answer: B) Rationale: Once the diagnosis is made, the
child should not bear weight on the affected hip, as
weight bearing can increase the amount of slippage.
Wheelchair use should be avoided, as this also may
increase the amount of slippage.
86. Which of the following symptoms is not typical in an
adolescent with idiopathic structural scoliosis?
a. Back pain
b. Skirts that hang unevenly
c. Unequal shoulder heights
d. Uneven waist angles
(Answer: A) Rationale: Back pain is not identified as a
symptom of idiopathic structural scoliosis. All the other
listed symptoms are.
87. Which nursing diagnosis should take highest priority
when working with an adolescent with scoliosis?
a. Body image disturbance related to treatment of
scoliosis
b. Diversional activity deficit related to treatment of
scoliosis
c. Anxiety related to outcome of treatment for
scoliosis
d. Fear related to treatment and unknown
outcomes
(Answer: A) Rationale: Treatment for scoliosis extends
over a long period of time, during the time when a great
deal of their psychological identity is formed. Treatment
involves a modified lifestyle and being “different” from
their peers, so issues of self-image are paramount and
should take priority.
88. Postoperative care of an adolescent following a
spinal fusion for scoliosis includes:
a. Oral analgesia for pain
b. Logrolling every 4 hours
c. Nasogastric intubation
d. Straight catheterization every 4 hours
(Answer: C) Rationale: There is some degree of paralytic
ileus following a spinal fusion; therefore, nasogastric
intubation is required along with frequent assessment of
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return of bowel function. The pain experienced by this
client is severe and requires intravenous medication,
preferably with patient-controlled analgesia (PCA).
Logrolling must be done every 2 hours, once allowed, to
prevent the accumulation of secretions in the lungs.
Urinary retention is common, and an indwelling catheter
is used id present rather than repeated straight
catheterization.
89. A 3-year-old child is suspected of having Duchenne’s
muscular dystrophy. Which of the following assessment
findings by the nurse would support this diagnosis?
a. A history of delayed crawling
b. Inability to ambulate independently
c. Difficulty climbing stairs
d. Gower’s sign
(Answer: C) Rationale: The child with Duchenne’s
muscular dystrophy has a history of meeting early
developmental milestone. Symptoms usually begin at
around 3 years of age and include difficulty-climbing
stairs, running, and pedaling. As the disease progresses,
the child has a difficult time ambulating on even
surfaces, and Gower’s sign is seen. The child loses the
ability to ambulate independently by the age of 10 to 12.
90. A child is suspected of having osteomyelitis. Which
of the following blood values supports this diagnosis?
a. Decreased white blood cell (WBC) count
b. Positive blood cultures
c. Increased hematocrit (Hct)
d. Increased BUN
(Answer: B) Rationale: Blood studies in a child with
osteomyelitis will reveal an increased WBC count, C-
reactive protein, and sedimentation rate. The blood
culture is usually positive. This disease process does not
affect the HCT or BUN.
91. A 4-year-old child was just diagnosed with impetigo.
What is the most important action the nurse should take
to make sure it does not spread?
a. Apply bacitracin
b. Keep it covered
c. Isolate the child at home
d. Teach and use good handwashing
(Answer: D) Rationale: Handwashing is always the most
important action that a nurse can take to prevent the
spread of infection. Merely applying ointment or covering
the site does not address the spread of infection, nor
does isolation of a child at home. The nurse would teach
the family the importance of good handwashing.
92. Which of the following would be appropriate home
care instructions for a family that has a lice infestation?
a. Immerse combs and brushes in boiling water for
30 minutes to kill lice
b. Vacuum floor and furniture to remove hair that
might have live nits
c. Take the child’s clothing and bed linens to a dry
cleaner for sanitation
d. Use commercial anti-lice sprays on furniture and
mattresses
(Answer: B) Rationale: Live nits can hatch up to 8 to 10
days later, so it is important to remove them from the
environment. Soaking combs in a Lysol or anti-lice
shampoo moisture will kill lice or nits. Dry cleaning is not
necessary because home washing and drying on hot
settings will b sufficient to kill lice and nits. Use of
commercial sprays is not recommended.
93. A 10-year-old child sustained partial thickness burns
to his right arm and abdomen after tossing gasoline on a
fire. What would the nurse expect the appearance of the
45
burn site to be?
a. Smooth and bright red
b. Bright red with numerous blisters
c. White and waxy
d. Dark brown and firm
(Answer: B) Rationale: The characteristics appearance
of second-degree burns is bright red skin with blisters of
varying sizes. A first-degree burn typically only has pink
or red skin. A third-degree burn may be dark in color,
from deep red to black.
94. Permethrin 5% (Elimite) is prescribed for a 10-year-
old child diagnosed with scabies. What instructions
should the nurse provide for the mother?
a. Apply the lotion liberally from head to toe
b. Wrap the child in a clean sheet after treatment
c. Leave the lotion on for 4 to 6 hours
d. Apply lotion only after the child has had a bath
and dried thoroughly
(Answer: D) Rationale: Permethrin is applied to cool dry
skin after a bath, but only from the neck down. The child
may dress after the lotion is applied. It should be washed
off after 8 to 12 hours. A second application of often
prescribed for 1 week later.
95. When assessing a child with a possible diagnosis of
facial cellulitis, the nurse will want to question the parent
about the recent history of:
a. Otitis media
b. Cat scratch
c. Sunburn
d. Sinusitis
(Answer: A) Rationale: A recent history of otitis media is
often present in children with facial cellulitis. Sunburn
would present as more diffuse and widespread redness.
An insect or animal bite can be a cause of cellulitis, but
in the case of a cellulitis on the face the nurse would
question a recent history of an ear infection if a bite were
not obvious.
96. In teaching a group of school children, a nurse would
explain that lice on a child could be most easily spread
by:
a. Sitting close to someone who had lice
b. Sharing hats at recess
c. Riding in the same car
d. Riding on the same bus
(Answer: B) Rationale: Lice can only be passed by direct
contact because lice do not fly. The usual mode of
transmission is sharing of hats, combs, brushes, or hair
ornaments. Being close to someone in a classroom, bus,
or car does not presuppose direct contact with hair or
nits that have been shed on hair.
97. What would be an appropriate nursing goal for a 10-
year-old girl with eczema of the elbows, hands, and
face?
a. Pain will be managed
b. Spread of infection will be prevented
c. Wee-hydrated skin will be maintained
d. Dietary restriction will be maintained
(Answer: C) Rationale: Keeping the skin well hydrated
will prevent the need to scratch dry skin that can lead to
excoriation and secondary infection. Eczema is not
infectious, nor is it managed by dietary restrictions.
Pruritus, not pain, is associated with eczema.
98. A 5-year-old boy was brought to the Emergency
Department after being burned trying to put out a fire
that started in his closet where he was playing with
matches. What should be the priority nursing
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assessment?
a. Level of pain
b. Airway patency
c. Psychosocial needs
d. Signs of infection
(Answer: B) Rationale: Because he was in close
proximity to the fire and tried to put it out, he is at risk of
having inhaled smoke and therefore having a
compromised airway. Assessing pain, psychosocial
needs, or for infection occurs only after establishing
airway patency.
99. Intravenous morphine is ordered for a 13-year-old
boy hospitalized with major burns to 30 percent of his
body. What is the rationale for IV morphine?
a. Longer half-life
b. Predictable absorption rate
c. Prevents ileus
d. Fewest side effects
(Answer: B) Rationale: The predictable rate of
absorption makes IV morphine useful in treating severe
pain. Side effects, including ileus, are considered
secondary to the desired effect of predictability in
managing pain. Knowing the half-life is not a rationale for
use of IV morphine.
100. The nurse is providing a teaching session for
parents about over-the-counter treatment for head lice.
Which of the following will be mentioned as appropriate
for treating this problem?
a. Neosporin
b. Mafenide (Sulfamylon)
c. Silver sulfadiazine (Silvadene)
d. Permethrin (Nix)
(Answer: D) Rationale: Permethrin is the over-the-
counter treatment of choice for head lice. Other choices
are topical agents, but they would not be used for lice.
Option 1 would be used for infection, while options 2 and
3 would be used to treat burns.
101. The nurse has explained allergy-proofing the home
to the mother of a child with dust allergies. Which
statement by the mother indicates a clear understanding
of appropriate allergy proofing?
a. “I’m going to replace the cotton curtains on the
window with blinds.”
b. “The only toys allowed in his bedroom are his
stuffed toys.”
c. “I should store his out-of-season clothes in his
bedroom.”
d. “The mattress and box springs both need to be
enclosed in a thick plastic cover.”
(Answer: D) Rationale: Cloth items hold in dust. Only
essential items should be stored in the child’s bedroom
and those should be in drawers or closets. Stuffed
animals retain dust and should be removed from the
bedroom. Cotton curtains would be preferred over blinds
because cotton curtains can be washed frequently. Both
the mattress and the bed should be enclosed in special
plastic covers to eliminate a source of dust.
102. A child is in the clinic for a prick test. Because of
the risk of anaphylaxis, the nurse has available for
emergency treatment:
a. Epinephrine
b. Corticosteroids
c. Narcan
d. Cromolyn sodium
(Answer: Prick tests determine allergens. Should the
child have an allergy, epinephrine might be needed to
counteract anaphylaxis.
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103. A mother brings a 3-year-old child to the clinic for a
well-child checkup. The child has not been to the clinic
since 6 months of age. What is the priority of care for
this child?
a. Assess growth and development
b. Begin dental care
c. Update vaccinations
d. Complete hearing screening
(Answer: C) Rationale: Every time a child enters the
healthcare system, the immunization status should be
checked. Some children have uncertain history of
immunization because of parental noncompliance or
special circumstances such as being refugees.
104. The mother of a 1-year-old child says that
breastfeeding her infant is sufficient to provide immunity.
She does not want to sigh the permit for immunizations.
What is the nurse’s best response?
a. Discuss activate and passive immunity
b. Tell her immunizations are legally mandatory
c. Ask about the mother’s diet
d. Allow her the right to refuse
(Answer: A) Rationale: Infants receive passive immunity,
which lasts 3 to 4 months through the placenta or
breastmilk. Active immunity lasts long term and is
acquired by exposure to disease or immunizations.
Option 1 addresses the client’s need for information.
105. The nurse is caring for several children on a
hospital unit where there has been a recent outbreak of
diarrhea. None of these children were admitted for
diarrhea, but the nurse is aware that they may be
exposed. Of the children on the unit, the one most
susceptible would be the:
a. Toddler with SCID
b. Preschooler in traction for a fractured femur
c. School-age child with eczema
d. Teenager with frequent stools secondary to
malabsorption syndrome
(Answer: A) Rationale: The immunocompromised child
would be the one at greatest risk for acquiring an
infectious organism. The other children would be at less
risk for acquiring the gastrointestinal infection.
106. A child is admitted to the hospital with an allergic
reaction. The physician orders a CBC with differential.
The nurse would expect to see an elevation in the level
of:
a. RBCs
b. Hemoglobin
c. Leukocytes
d. Eosinophils
(Answer: D) Rationale: Eosinophils are the white blood
cell associated with allergic reactions.
107. A child is being discharged from the nursery with a
positive TORCH titer. Parents should be informed that:
a. The child may shed the virus for a year
b. TORCH is a genetic disorder
c. No follow-up is necessary
d. Medication will not be needed for this condition
(Answer: A) Rationale: TORCH is an acronym for a set
of microbes that includes toxoplasmosis, syphilis,
hepatitis, rubella, cytomegalovirus, and herpes simplex.
If an infant has one of the viruses, they could be shed for
up to 1 year.
108. An infant with AIDS will be attending daycare. The
daycare workers are concerned about spreading the
virus. The public health nurse is explaining to the
workers the precautions they should take. These
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precautions include:
a. Storing all of this infant’s supplies separately
from the other children
b. Wearing gloves when changing the child’s
diapers
c. Always wearing gloves and isolation gowns
when handling the infant
d. Minimizing contact with the infant when he is
febrile
(Answer: B) Rationale: The HIV virus is spread by blood
and body fluids. Clean gloves should be worn when
changing the diapers as it exposes the worker to body
fluids. The other answers are incorrect.
109. A mother overhears two nurses discussing a
measles outbreak. The nurses are talking about the
incubation period. The mother asks the nurses why it is
important to know the incubation period for a childhood
disease. The nurse’s reply would be based on the
knowledge that the incubation period:
a. Describes a period when the child might be
contagious
b. Determines the severity of the infection
c. Varies depending on the age of the child
d. Is a period of time when medications can
prevent the development of symptoms
(Answer: A) Rationale: The incubation period is the time
between exposure and outbreak of the disease. It is
often a period when the child can be contagious without
others being aware of the possible exposure.
110. An infant is admitted to the pediatric hospital
straight from the birth hospital with numerous congenital
defects and a diagnosis of rule out TORCH syndrome.
The father tells the pediatric nurse that he and his wife
had planned a beautiful birth experience and can’t
believe what’s happened. An appropriate nursing
diagnosis for this family would be:
a. Risk for caregivers role strain
b. Situational low self-esteem
c. Risk for altered parent/infant attachment
d. Parental role conflict
(Answer: C) Rationale: With the birth of a less-than
expected infant, the parents may have difficulty
accepting the child. In addition, the prolonged
hospitalization and separation from the parents inhibit
bonding, which could lead to altered attachment.
111. A school-age child is being admitted for surgical
removal of a brain tumor. Expected nursing
assessments during the preoperative period would
include:
a. Bulging fontanels
b. Vomiting
c. Drainage from the ear or nose
d. Elevated blood glucose levels
(Answer: B) Rationale: Vomiting is a symptom of
increased intracranial pressure. Bulging fontanels would
not be present in a school-age child. Drainage from the
ear or nose might indicate a basilar skull fracture, not a
brain tumor. Some brain tumors display the symptom of
diabetes insipidus, not diabetes mellitus, thus the
symptom would be dilute urine rather than elevated
blood glucose.
112. A child is receiving chemotherapy to induce
remission in acute leukemia. When considering common
side effects of chemotherapy, an appropriate nursing
diagnosis early in the course of therapy would include:
a. Sleep pattern disturbance
b. Altered mucous membranes
47
 c. Risk for infection
d. Risk for impaired tissue perfusion peripheral
(Answer: B) Rationale: nausea and vomiting, anorexia,
mouth sores, constipation, and pain are early and
common side effects of chemotherapy. Bone marrow
suppression reaches its peak 7 to 10 days after
induction. Sleep pattern disturbance may be related but
is not directly caused by chemotherapy.
113. A client is to begin radiation therapy after the
removal of Wilms’ tumor. The parent statement that
indicates a lack of understanding of related skin care
would be:
a. “We will use loose-fitting clothes on our child.”
b. “We will protect our child from sun exposure.”
c. “We will keep the area moist with Vaseline.”
d. “We will prevent our child from scratching the
site.”
(Answer: C) Rationale: Self-care during external
radiation therapy includes loose-fitting clothes, gentle
washing with mild soap, avoiding sun exposure, and
avoiding scratching and other irritation. Any lubricant
must be water-soluble.
114. An adolescent on consolidation chemotherapy for
acute lymphocytic leukemia (ALL) asks the nurse to
come quickly to evaluate “blood in my urine.” The nurse
would do which of the following as the most important
action?
a. Explain this is normal for these drugs
b. Measure intake and output
c. Force fluids to improve the hematuria
d. Recognize that this is untoward and report the
event
(Answer: D) Rationale: This is an untoward effect of the
commonly used cancer medication cyclophosphamide
(Cytoxan) and should be reported. Fluids are usually
forced prior to administration and the bladder is emptied
frequently to prevent hematuria. Measuring intake and
output should be done routinely on all clients and is not
specific to managing this complication.
115. A client is being admitted for mild neutropenia and
a severe oral monilial infection. The nurse should assign
the child to which room?
a. A semi-private room with a medical patient
b. A semi-private room with a surgical patient
c. A private room without further precautions
d. A private room with protective isolation
(Answer: C) Rationale: A private room assignment is
indicated for children with chemotherapy-related
neutropenia. Careful handwashing is also an essential
element to reduce the risk of infection.
116. You are assigned to the postoperative care of a
client with a below-the-knee amputation for osteogenic
sarcoma. Nursing care of the child would include:
a. Maintaining bedrest until able to use permanent
prosthesis
b. Keeping stump elevated continuously until
prosthesis applied
c. Applying a dressing to the stump that allows
continuous visualization of the distal stump
d. Encouraging early visits from friends
(Answer: D) Rationale: Nursing care must be supportive
of body image adjustment. The child would be
encouraged to sit in a chair and ambulate on crutches
while waiting for the permanent prosthesis. The stump
dressing is a continuous ace bandage, which supports
the stump shape in preparation for the prosthesis.
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117. The nursing diagnosis for a child undergoing
chemotherapy for leukemia is Altered nutrition: less than
body requirements related to nausea and anorexia. An
appropriate goal for this client would be:
a. Administer antiemetics PRN
b. The child’s caloric intake will be within normal
range
c. The child does not complain of nausea
d. Intake and output are approximately equal
(Answer: B) Rationale: The client’s goal is stated in
terms of behaviors of the child that demonstrate the
problem is solved. Option 1 is a nursing action, not a
goal. Absence of nausea does not guarantee adequate
intake. Equal intake and output does not indicate
adequate nutrition.
118. A child is to receive chemotherapy intravenously
with a vesicant drug. The nurse can ensure safe
administration of this drug by:
a. Administering the drug using a positive pressure
infusion pump
b. Checking for blood return before, during and
after administration of the drug
c. Maintaining the infusion site below the level of
the heart
d. Delivering the infusion as rapidly as possible
(Answer: B) Rationale: By checking for blood return
throughout the administration, the nurse can stop the
infusion at any time blood return does not occur. A
positive pressure infusion pump, maintaining the infusion
site below the level of the heart, or rapid drug delivery
does not guarantee the infusion will not extravasate.
119. A child with leukemia has developed pancytopenia.
Measures designed to reduce stomatitis in this child
while receiving chemotherapy would include:
a. Alcohol-based mouthwash to reduce oral
organisms
b. Brushing the teeth twice a day with a firm-
bristled toothbrush
c. Increasing intake of citrus juices, such as orange
juice, that contain vitamin C
d. Rinsing the mouth several times a day with plain
water
(Answer: D) Rationale: Studies have shown that simply
rinsing the mouth with water decreases the onset of
stomatitis in clients receiving chemotherapy. Alcohol-
based mouthwash would be avoided as it is drying to the
oral mucous membranes. A stiff toothbrush may cause
the gums to bleed. Should oral lesions be present, acidic
foods ands liquids will increase discomfort.
120. During rounds, the interdisciplinary team is
discussing a child with leukemia who has just been
diagnosed as terminally ill. The nurses describe the
mother’s behavior as angry, claiming the nurses are not
providing care for her child. The team leader will focus
on the probable cause of the mother’s anger, which is:
a. Poor care on the part of the nurses
b. Lack of attention for the mother’s needs
c. Overwhelming guilt for having caused the
leukemia
d. A stage of bereavement over the anticipated
loss of the child
(Answer: D) Rationale: The stages of grief and
bereavement include denial, anger, bargaining,
depression, and acceptance. The anger expressed may
often be displaced and directed towards persons who
have a role in the loss. Nursing and other healthcare
personnel must be aware of this in order to help the
family cope with the impending loss.
48

121. The best rationale to give parents who are
questioning the use of elbow restraints with their child
who has had cleft palate repair is:
a. “This device is frequently used postoperatively
to protect the IV site in small children.”
b. “The restraints will help us maintain proper body
alignment.”
c. “Elbow restraints are used postoperatively to
keep their hands away from the surgical site.”
d. “The restraints help us remember that the child
is NPO after surgery.”
(Answer: C) Rationale: Elbow restraints are used to keep
hands away from the mouth after cleft palate surgery.
This precaution will be maintained at home until the
palate is healed, usually 4 to 6 weeks.
122. The nurse is caring for an infant vomiting secondary
to pyloric stenosis. The mother questions why the
vomitus of this child appears different from that of her
other children when they have the flu. The nurse would
explain that the emesis of an infant with pyloric stenosis
does not contain bile because:
a. The GI system is still immature in newborns and
infants
b. The obstruction is above the bile duct
c. The emesis is from passive regurgitation
d. The bile duct is obstructed
(Answer: B) Rationale: In pyloric stenosis, bile is unable
to enter the stomach from the duodenum because the
pylorus muscle is hypertrophied, which causes the
obstruction.
123. The nurse is teaching the parent of a child with
celiac disease about the dietary restrictions. The nurse
would explain that the most appropriate diet for their
child is:
a. Gluten-free
b. Salt-free
c. Fat-free
d. High-calorie, low-fat
(Answer: A) Rationale: Most children who remain on a
gluten-free diet are healthy and free of symptoms and
complications.
124. A high school experiences an outbreak of hepatitis
B. In teaching the high school students about hepatitis B,
the nurse would explain:
a. Hepatitis B cannot exist in carrier state
b. Hepatitis B is primarily transmitted through the
fecal-oral route
c. Immunity to all types of hepatitis will occur after
this current attack
d. Hepatitis B can be prevented by receiving the
HBV vaccine
(Answer: D) Rationale: HBV vaccine provides active
immunity and current recommendations include
immunizations for all newborns, as well as several high-
risk groups. Hepatitis B is spread by blood and body
fluids, including through sexual contact.
125. A 4-year-old child is admitted to the unit with
moderate dehydration. Which of the following symptoms
led the physicians to the diagnosis of moderate
dehydration in this child?
a. Elevated heart rate and sunken fontanel
b. Increased thirst and urine specific gravity of
1.038
c. Weight gain and decreased skin turgor
d. Oliguria and urine specific gravity of 1.010
(Answer: B) Rationale: The nurse would expect an
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increased desire to drink fluids and a higher specific
gravity caused by the concentration of urine. Although
the heart rate would be elevated, the fontanels are
closed on a 4-year-old. The degree of dehydration is
based on the percent of weight loss so a weight gain
would not be likely. Diminished urine output is an
expected normal finding in dehydration, however the
urine specific gravity would also be affected.
126. While performing a newborn assessment, the nurse
notices the infant is having difficulty breathing. Nasal
flaring, cyanosis, ands retractions are observed and
there are no breath sounds on the left side. The apical
pulse is auscultated on the right side of the chest. The
nurse would notify the physician immediately because
he or she suspects:
a. Diaphragmatic hernia
b. Pyloric stenosis
c. Cleft palate
d. Omphalocele
(Answer: A) Rationale: Clinical findings will vary in
infants born with congenital diaphragmatic hernias but
the first indications are of respiratory distress. Further
assessment will reveal bowel sounds auscultated over
the chest, cardiac sounds auscultated over the chest,
cardiac sounds on the right of the chest, and a sunken
abdomen with a barrel-shaped chest.
127. The nurse has taught dietary restrictions to the 7-
year-old child with celiac disease. After teaching, the
child is allowed to choose a correct menu. The nurse
would know that teaching was effective when the child
chooses:
a. Beef and barely soup, rice cakes, and celery
b. Ham and cheese sandwich with lettuce and
tomato on rye toast
c. Beef patty on a hamburger bun and French fries
d. Baked chicken, green beans, and a slice of
cornbread
(Answer: D) Rationale: Celiac disease is characterized
by intolerance for gluten. Gluten is found in wheat,
barley, rye, and oats. This includes bread, cake,
doughnuts, cookies, and crackers, as well as processed
foods that contain gluten as filler.
128. An infant returns from initial surgery for
Hirschsprung’s disease. Because of the type of surgery
the child had, the nurse would exclude from the routine
postoperative plan-of-care instructions to:
a. Maintain the child NPO until bowel sounds
return
b. Monitor rectal temperature every 4 hours
c. Reunite the parents with the child as soon as
possible
d. Assess the surgical site every 2 hours
(Answer: B) Rationale: The corrective surgery for
Hirschsprung’s disease requires pulling the end of the
normal bowel through the muscular sleeve of the rectum.
With this type of procedure, rectal temperatures and any
invasive procedure would be avoided to allow proper
healing to occur.
129. A 3-month-old infant has gastroesophageal reflux
(GER) but is thriving without other complications. The
mother wants to know if there is anything she can do
differently to decrease the reflux. Which of the following
interventions should the nurse suggest to minimize
reflux?
a. Discontinue breast-feeding immediately
b. Decrease frequency of feedings as much as
possible
c. Place the baby in prone position with the head
49
 elevated
d. Place the infant in a car seat after feeding
(Answer: C) Rationale: Infants with GER should be given
small, frequent feedings. After a feeding the infant
should be placed in a prone position with the head of the
bed elevated. After a feeding the infant should be placed
in a prone position with the head of the bed elevated. A
harness can be used to help maintain this position.
Infant seats should be avoided because of the increased
intra abdominal pressure this position creates.
130. A 10-year-old boy has been admitted with a
diagnosis of “rule out appendicitis.” While the nurse was
conducting a routine assessment, the boy stated, “It
doesn’t hurt anymore.” The nurse suspects that:
a. The boy is afraid of going to surgery
b. The boy is having difficulty expressing his pain
adequately
c. The appendix has ruptured
d. This is a method the boy uses to receive
attention
(Answer: C) Rationale: Signs and symptoms of a
ruptured appendix include fever, sudden relief from
abdominal pain, guarding, abdominal distention, rapid
shallow breathing, pallor, chills, and irritability.
131. A 2-year-old with hemophilia is being discharged,
and the nurse is completing discharge teaching with his
parents. Which of the following statements by the
parents indicates they require further teaching regarding
hemophilia?
a. “It is good to know that his sister will not get
hemophilia also.”
b. “If our son has a temperature, we will not give
aspirin or ibuprofen, only acetaminophen.”
c. “We will get a Medic-Alert bracelet for our son as
soon as we get home.”
d. “We will be sure to watch our son very closely to
make sure he does not have another episode of
bleeding.”
(Answer: D) Rationale: It is not possible for parents of a
hemophiliac to prevent a bleeding episode, no matter
how careful they are. The nurse should reinforce this
information along with methods for decreasing the
chance of an injury that will lead to a bleeding episode.
The other statements all indicate an appropriate
understanding of hemophilia.
132. The parents of a client with sickle cell anemia are
asking for information about future pregnancies. Neither
parent has sickle cell anemia. The nurse would provide
them with the information that nay future pregnancies
will have a:
a. 1 in 4 chance of producing a child with sickle cell
trait
b. 1 in 4 chance of producing a child with sickle cell
anemia
c. 1 in 2 chance of producing a child with neither
sickle cell disease or trait
d. 1 in 2 chance of producing a child with sickle cell
anemia
(Answer: B) Rationale: Sickle cell anemia is an
autosomal recessive condition. Therefore, if both parents
have the trait, each pregnancy carries a 25 percent risk
that the child will have the disease.
133. The nurse is working with the family of an 8-month-
old infant with severe nutritional anemia. In providing
dietary recommendations, the nurse should instruct the
family to:
a. Switch the baby to cow’s milk
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b. Delay the introduction of table food in the diet
c. Restrict the amount of milk or formula in the
baby’s diet to 1 quart per day
d. Provide dietary iron sources such as peanuts
ands unsweetened chocolates
(Answer: C) Rationale: Many infants with nutritional
anemia rely primarily on the milk/formula for dietary
intake and refuse solid foods. When the milk/formula is
limited, the child will be more willing to take solid foods.
Cow’s milk is a poor source if iron. Peanuts and
unsweetened chocolates are sources of iron but are not
appropriate for a child this age.
134. A child is being admitted to the unit with
thalassemia major. In preparing client assignments, the
charge nurse would wan tot assign a nurse to this child
who can:
a. Teach dietary sources of iron
b. Administer blood transfusions
c. Work with a dying child
d. Monitor the child for bleeding tendencies
(Answer: B) Rationale: Blood transfusions are utilized in
order to maintain normal hemoglobin levels. This child
has an excess of iron secondary to repeated
transfusions and, thus, iron supplements will not be
necessary. The other therapies are inappropriate for the
child with thalassemia major.
135. The nurse is caring for a child who is being treated
for extensive bleeding in the Emergency Department.
The source and extent of bleeding are being determined
as the nurse is trying to control the bleeding. Which of
the following actions takes priority?
a. Obtain the client’s history
b. Talk with the family regarding the risk of HIV and
hepatitis C with blood transfusions
c. Replace blood volume
d. Provide psychosocial support to the family
(Answer: C) Rationale: Appropriate oxygenation is not
possible when there is significant loss of blood volume.
Replacing the blood volume is critical to saving the
child’s life, and it is imperative that replacement occurs
prior to any of the listed nursing actions.
136. The nurse is working with the family of a toddler
who is being treated for iron-deficiency anemia. In
teaching dietary considerations, the nurse will instruct
the family to add sources of iron and:
a. Vitamin D and thiamine
b. Calcium and riboflavin
c. Carbohydrates and vitamins
d. Folic acid and proteins
(Answer: D) Rationale: Folic acid potentiates the
removal of iron form ferritin, which makes it further
available for heme production. The synthesis of albumin,
blood proteins, fibrinogen, and hemoglobin is dependent
upon the presence of proteins. None of the others are
involved in building RBCs.
137. The elementary school nurse is assessing and
giving initial care to a hemophiliac who has a significant
pain in his knee. The nurse suspects hemarthrosis. As
the nurse waits for his family to pick up the child, the
nurse would:
a. Maintain joint mobility with passive range of
motion exercises
b. Elevate the leg above his heart
c. Administer children’s aspirin or ibuprofen for
pain
d. Apply warm soaks to reduce the swelling
(Answer: B) Rationale: Elevate the leg above the level of
50
the heart to reduce bleeding. Aspirin or aspirin-like
products such as ibuprofen interfere with the clotting
mechanisms. During active bleeds, the joint should be
immobilized. Warm soaks would promote bleeding; ice
packs should be used instead.

138. The nurse has admitted a 2-year-old in vaso-

occlusive crisis. AS the nurse starts the initial
assessment, the child insists upon lying in bed, on her
side with her knees flexed to the abdomen. The nurse
would want to further assess the child for the presence
of:
a. Stomach pain
b. Nausea
c. Constipation
d. Fear secondary to the impact of hospitalization
(Answer: A) Rationale: Such positioning indicates the
likelihood of abdominal pain. Nausea or constipation
does not generally cause a child to self-position as
described. Fear related to the hospitalization would be
common in a child this age. However, if this were the
case, it is more likely the child would seek refuge in the
arms of one of her parents.

139. The 10-year-old client in the Emergency

Department has CBC results that include hemoglobin of
eight g/dL and hematocrit of 24 percent. The nursing
activity with the highest priority is:
a. Assessing and promoting skin integrity
b. Promoting hydration
c. Promoting nutrition
d. Conserving energy
(Answer: D) Rationale: Such lab results indicate severe
anemia. Fatigue results when the oxygen-carrying
capacity of RBCS is impaired and cellular hypoxia is
present. Fatigue can be diminished and oxygen
depletion limited when the client’s energy is conserved.
There will be an increased oxygen requirement and
increased fatigue with increased mobility. Increasing
general hydration without transfusing RBCs will not
positively affect the anemic state. Skin integrity is not a
high priority at this point. Although improving nutrition is
appropriate, the response would not be immediate. The
priority activity would be conserving energy and reducing
cardiac stress.

140. The nurse is caring for a child diagnosed with

thalassemia major who is receiving her first chelation
therapy. The parents ask the purpose of chelation
therapy. The best response by the nurse is that chelation
therapy is done to:
a. Decrease the risk of hypoxia
b. Decrease the risk of bleeding
c. Eliminate excess iron
d. Prevent further sickling of RBCs
(Answer: C) Rationale: Chelation therapy works to rid
the body of excess iron storage that results from the
frequent hemoglobin. Chelation will have no effect upon
hypoxia or bleeding. Sickling of RBCs does not occur
with thalassemia.

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