1.

The student nurse is assigned to take the vital signs of the clients in the pediatric
ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2
days postoperative after a cleft palate repair has given the toddler a pacifier. What
would be the best immediate action of the nurse?

A. Notify the pediatrician of this finding

B. Reassure the student that this is an acceptable action on the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the pacifier from the toddler’s mouth
2. The nurse is providing a health teaching to the mother of an 8-year-old child with
cystic fibrosis. Which of the following statement if made by the mother would
indicate to the nurse the need for further teaching about the medication regimen of the
child?

A. “My child might need an extra capsule if the meal is high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
3. The mother brought her child to the clinic for follow-up check up. The mother tells
the nurse that 14 days after starting an oral iron supplement, her child’s stools are
black. Which of the following is the best nursing response to the mother?

A. “I will notify the physician, who will probably decrease the dosage slightly”
B. “This is a normal side effect and means the medication is working”
C. “You sound quite concerned. Would you like to talk about this further?”
D. “I will need a specimen to check the stool for possible bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother
asks the nurse if the treatment given to her son is effective. What would be the
appropriate response of the nurse?

A. I will review first the child’s height on a growth chart to know if the treatment is
working
B. I will review first the child’s weight on a growth chart to know if the treatment is
working
C. I will review first the number of prescriptions refills the child has required over
the last 6 months to give you an accurate answer
D. I will review first the number of times the child has seen the pediatrician during
the last 6 months to give you an accurate answer
5. The nurse is caring to a child client who is receiving tetracycline. The nurse is
aware that in taking this medication, it is very important to:
 A. Administer the drug between meals
B. Monitor the child’s hearing
C. Give the drug through a straw
D. Keep the child out of the sunlight
6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure
is brought to the emergency department. During assessment, the nurse checks the
apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of
the following is the appropriate nursing action?

A. Retake the apical pulse in 15 minutes

B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled
7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving
chemotherapy. Before administering the drug, the nurse should check the results of
the child’s:

A. CBC and platelet count

B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays
8. Which of the following is the suited size of the needle would the nurse select to
administer the IM injection to a preschool child?

A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with
salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic
fever. Which of the following activities performed by the child would give a best sign
that the medication is effective?

A. Listening to story of his mother

B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player
10. The physician decided to schedule the 4-year-old client for repair of left
undescended testicle. The Injection of a hormone, HCG finds it less successful for
treatment. To administer a pentobarbital sodium (Nembutal) suppository
preoperatively to this client, in which position should the nurse place him?
 A. Supine with foot of bed elevated
B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg flexed
11. The nurse is caring to a 24-month-old child diagnosed with congenital heart
defect. The physician prescribed digoxin (Lanoxin) to the client. Before the
administration of the drug, the nurse checks the apical pulse rate to be 110 beats per
minute and regular. What would be the next nursing action?

A. Check the other vital signs and level of consciousness

B. Withhold the digoxin and notify the physician
C. Give the digoxin as prescribed
D. Check the apical and radial simultaneously, and if they are the same, give the
digoxin.
12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will
undergo a chest physiotherapy treatment. The therapy should be properly coordinated
by the nurse with the respiratory therapy department so that treatments occur during:

A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
13. The nurse is providing health teaching about the breastfeeding and family
planning to the client who gave birth to a healthy baby girl. Which of the following
statement would alert the nurse that the client needs further teaching?

A. “I understand that the hormones for breastfeeding may affect when my periods
come”
B. “Breastfeeding causes my womb to tighten and bleed less after birth”
C. “I may not have periods while I am breastfeeding, so I don’t need family
planning”
D. “I can get pregnant as early as one month after my baby was born”
14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The
nurse assigned to the client enters the client’s room and finds out that the client is
using a soiled blanket brought in from home. The nurse attempts to remove the
blanket and replace it with a new and clean blanket. The toddler refuses to give the
soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior
is:

A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
 C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task of the child. In caring a 3-
year-old-client, the nurse knows that the suited developmental task of this child is to:

A. Learn to play with other children

B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment
16. A mother who gave birth to her second daughter is so concerned about her 2-year
old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not
accept her newly born sister”. It is appropriate to the nurse to response that:

A. The older daughter be given more responsibility and assure her “that she is a big
girl now, and doesn’t need Mommy as much”
B. The older daughter not have interaction with the baby at the hospital, because she
may harm her new sibling
C. The older daughter stay with her grandmother for a few days until the parents and
new baby are settled at home
D. The mother spend time alone with her older daughter when the baby is sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go
to the playroom. Which of the following is an appropriate toy would the nurse select
for the child:

A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
18. Which of the following clients is at high risk for developmental problem?

A. A toddler with acute Glomerulonephritis on antihypertensive and antibiotics

B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic fibrosis
19. Which of the following would be the best divesionary activity for the nurse to
select for a 2 weeks hospitalized 3-year-old girl?

A. Crayons and coloring books

B. doll
C. xylophone toy
D. puzzles
20. A nurse is providing safety instructions to the parents of the 11-month-old child.
Which of the following will the nurse includes in the instructions?

A. Plugging all electrical outlets in the house

B. Installing a gate at the top and bottom of any stairs in the home
C. Purchasing an infant car seat as soon as possible
D. Begin to teach the child not to place small objects in the mouth
21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new
school. While the child is focusing on adjusting to new environment and peers, her
grades suffer. The child’s father severely punishes the child and forces her daughter to
study after school. The father does not allow also her daughter to play with other
children. These data indicate to the nurse that this child is deprived of forming which
normal phase of development?

A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to
do preoperative teaching with the child. The nurse should knows that the 5-year-old
would:

A. Expect a simple yet logical explanation regarding the surgery

B. Asks many questions regarding the condition and the procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery
23. The nine-year-old client is admitted in the hospital for almost 1 week and is on
bed rest. The child complains of being bored and it seems tiresome to stay on bed and
doing nothing. What activity selected by the nurse would the child most likely find
stimulating?

A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming staff development meeting
D. Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike
very fast and with one hand. “It is making me crazy!” What would be the best
explanation of the nurse to the behavior of the boy?

A. The adolescent might have an unconscious death wish

B. The adolescent feels indestructible
 C. The adolescent lacks life experience to realize how dangerous the behavior is
D. The adolescent has found a way to act out hostility toward the parent
25. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring
for the client tells the mother to stay beside the infant while making assessment.
Which of the following developmental milestones the infant has reached?

A. Has a three-word vocabulary

B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers
26. The community nurse is conducting a health teaching in the group of married
women. When teaching a woman about fertility awareness, the nurse should
emphasize that the basal body temperature:

A. Should be recorded each morning before any activity

B. Is the average temperature taken each morning
C. Can be done with a mercury thermometer but not a digital one
D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus
test
27. The community nurse is providing an instruction to the clients in the health center
about the use of diaphragm for family planning. To evaluate the understanding of the
woman, the nurse asks her to demonstrate the use of the diaphragm. Which of
following statement indicates a need for further health teaching?

A. “I should check the diaphragm carefully for holes every time I use it.”
B. “The diaphragm must be left in place for at least 6 hours after intercourse.”
C. “I really need to use the diaphragm and jelly most during the middle of my
menstrual cycle
D. “I may need a different size diaphragm if I gain or lose more than 20 pounds”
28. The client visits the clinic for prenatal check-up. While waiting for the physician,
the nurse decided to conduct health teaching to the client. The nurse informed the
client that primigravida mother should go to the hospital when which patter is
evident?

A. Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have
ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong
menstrual cramps
C. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody
show
D. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
29. A nurse is planning a home visit program to a new mother who is 2 weeks
postpartum and breastfeeding, the nurse includes in her health teaching about the
resumption of fertility, contraception and sexual activity. Which of the following
statement indicates that the mother has understood the teaching?

A. “Because breastfeeding speeds the healing process after birth, I can have sex right
away and not worry about infection”
B. “Because I am breastfeeding and my hormones are decreased, I may need to use a
vaginal lubricant when I have sex”
C. “After birth, you have to have a period before you can get pregnant again’
D. “Breastfeeding protects me from pregnancy because it keeps my hormones down,
so I don’t need any contraception until I stop breastfeeding”
30. A community nurse enters the home of the client for follow-up visit. Which of the
following is the most appropriate area to place the nursing bag of the nurse when
conducting a home visit?

A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
31. The nurse in the health center is making an assessment to the infant client. The
nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects
that the infant has eczema. Which of the following is the most important nursing goal:

A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
32. The nurse in the health center is providing immunization to the children. The
nurse is carefully assessing the condition of the children before giving the vaccines.
Which of the following would the nurse note to withhold the infant’s scheduled
immunizations?

A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
33. A mother brought her child in the health center for hepatitis B vaccination in a
series. The mother informs the nurse that the child missed an appointment last month
to have the third hepatitis B vaccination. Which of the following statements is the
appropriate nursing response to the mother?
A. “I will examine the child for symptoms of hepatitis B”
B. “Your child will start the series again”
C. “Your child will get the next dose as soon as possible”
D. “Your child will have a hepatitis titer done to determine if immunization has
taken place.”
34. The community health nurse implemented a new program about effective breast
cancer screening technique for the female personnel of the health department of
Valenzuela. Which of the following technique should the nurse consider to be of the
lowest priority?

A. Yearly breast exam by a trained professional

B. Detailed health history to identify women at risk
C. Screening mammogram every year for women over age 50
D. Screening mammogram every 1-2 years for women over age of 40.
35. Which of the following technique is considered an aseptic practice during the
home visit of the community health nurse?

A. Wrapping used dressing in a plastic bag before placing them in the nursing bag
B. Washing hands before removing equipment from the nursing bag
C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a labeled container inside the
nursing bag
36. The nurse is planning to conduct a home visit in a small community. Which of the
following is the most important factor when planning the best time for a home care
visit?

A. Purpose of the home visit

B. Preference of the patient’s family
C. Location of the patient’s home
D. Length of time of the visit will take
37. The nurse assigned in the health center is counseling a 30-year-old client
requesting oral contraceptives. The client tells the nurse that she has an active yeast
infection that has recurred several times in the past year. Which statement by the
nurse is inaccurate concerning health promotion actions to prevent recurring yeast
infection?

A. “During treatment for yeast, avoid vaginal intercourse for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the parent of a 6-month-old infant
asks the health nurse, “Why is our baby going to receive so many immunizations over
a long time period?” The best nursing response would be:

A. “The number of immunizations your baby will receive shows how many pediatric
communicable and infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is determined by your
baby’s health history and age”
D. “It is easier on your baby to receive several immunizations rather than one at a
time”
39. The community health nurse is conducting a health teaching about nutrition to a
group of pregnant women who are anemic and are lactose intolerant. Which of the
following foods should the nurse especially encourage during the third trimester?

A. Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and
iron supplements
B. Prenatal iron and calcium supplements plus a regular adult diet
C. Red beans, green leafy vegetables, and fish for iron and calcium needs plus
prenatal vitamins and iron supplements
D. Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and
iron supplements
40. A woman with active tuberculosis (TB) and has visited the health center for
regular therapy for five months wants to become pregnant. The nurse knows that
further information is necessary when the woman states:

A. “Spontaneous abortion may occur in one out of five women who are infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact with my baby until
contagious is no longer a problem
D. “I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33 million people suffer from
food poisoning every year. Salmonella enteritis is responsible for almost 4 million
cases of food poisoning. One of the major goals is to promote proper food preparation.
The community health nurse is tasks to conduct health teaching about the prevention
of food poisoning to a group of mother everyday. The nurse can help identify signs
and symptoms of specific organisms to help patients get appropriate treatment.
Typical symptoms of salmonella include:

A. Nausea, vomiting and paralysis

B. Bloody diarrhea
 C. Diarrhea and abdominal cramps
D. Nausea, vomiting and headache
42. A community health nurse makes a home visit to an elderly person living alone in
a small house. Which of the following observation would be a great concern?

A. Big mirror in a wall

B. Scattered and unwashed dishes in the sink
C. Shiny floors with scattered rugs
D. Brightly lit rooms
43. The health nurse is conducting health teaching about “safe” sex to a group of high
school students. Which of the following statement about the use of condoms should
the nurse avoid making?

A. “Condoms should be used because they can prevent infection and because they
may prevent pregnancy”
B. “Condoms should be used even if you have recently tested negative for HIV”
C. “Condoms should be used every time you have sex because condoms prevent all
forms of sexually transmitted diseases”
D. “Condoms should be used every time you have sex even if you are taking the pill
because condoms can prevent the spread of HIV and gonorrhea”
44. The department of health is promoting the breastfeeding program to all newly
mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby
girl. The nursing care plan for a breast-feeding mother takes into account that breast-
feeding is contraindicated when the woman:

A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
45. The City health department conducted a medical mission in Barangay Marulas.
Majority of the children in the Barangay Marulas were diagnosed with pinworms. The
community health nurse should anticipate that the children’s chief complaint would
be:

A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
46. The mother brought her daughter to the health center. The child has head lice. The
nurse anticipates that the nursing diagnosis most closely correlated with this is:
 A. Fluid volume deficit related to vomiting
B. Altered body image related to alopecia
C. Altered comfort related to itching
D. Diversional activity deficit related to hospitalization
47. The mother brings a child to the health care clinic because of severe headache and
vomiting. During the assessment of the health care nurse, the temperature of the child
is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is
suspecting that the child might be suffering from bacterial meningitis. The nurse
continues to assess the child for the presence of Kernig’s sign. Which finding would
indicate the presence of this sign?

A. Flexion of the hips when the neck is flexed from a lying position
B. Calf pain when the foot is dorsiflexed
C. Inability of the child to extend the legs fully when lying supine
D. Pain when the chin is pulled down to the chest
48. A community health nurse makes a home visit to a child with an infectious and
communicable disease. In planning care for the child, the nurse must determine that
the primary goal is that the:

A. Child will experience mild discomfort

B. Child will experience only minor complications
C. Child will not spread the infection to others
D. Public health department will be notified
49. The mother brings her daughter to the health care clinic. The child was diagnosed
with conjunctivitis. The nurse provides health teaching to the mother about the proper
care of her daughter while at home. Which statement by the mother indicates a need
for additional information?

A. “I do not need to be concerned about the spreading of this infection to others in

my family”
B. “I should apply warm compresses before instilling antibiotic drops if purulent
discharge is present in my daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at nighttime if I have eye
discomfort”
D. “I should perform a saline eye irrigation before instilling, the antibiotic drops into
my daughter’s eye if purulent discharge is present”
50. A community health nurse is caring for a group of flood victims in Marikina area.
In planning for the potential needs of this group, which is the most immediate
concern?

A. Finding affordable housing for the group

B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate food, shelter and clothing are
available
Answers and Rationales
1. C. Nothing must be placed in the mouth of a toddler who just undergone a cleft
palate repair until the suture line has completely healed. It is the nurse’s
responsibility to inform the parent of the client. Spoon, forks, straws, and tongue
blades are other unacceptable items to place in the mouth of a toddler who just
undergone cleft palate repair. The general principle of care is that nothing should
enter the mouth until the suture line has completely healed.
2. D. The pancreatic capsules contain pancreatic enzyme that should be administered
in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to
maintain the medication’s integrity.
3. B. When oral iron preparations are given correctly, the stools normally turn dark
green or black. Parents of children receiving this medication should be advised
that this side effect indicates the medication is being absorbed and is working
well.
4. C. Reviewing the number of prescription refills the child has required over the
last 6 months would be the best indicator of how well controlled and thus how
effective the child’s asthma treatment is. Breakthrough wheezing, shortness of
breath, and upper respiratory infections would require that the child take
additional medication. This would be reflected in the number of prescription
refills.
5. D. Tetracycline may cause a phototoxic reaction.
6. D. The normal heart rate of an infant is 120-160 beats per minute.
7. C. Both gentamicin and chemotherapeutic agents can cause renal impairment and
acute renal failure; thus baseline renal function must be evaluated before initiating
either medication.
8. C. In selecting the correct needle to administer an IM injection to a preschooler,
the nurse should always look at the child and use judgment in evaluating muscle
mass and amount of subcutaneous fat. In this case, in the absence of further data,
the nurse would be most correct in selecting a needle gauge and length
appropriate for the “average’ preschool child. A medium-gauge needle (21G) that
is 1 inch long would be most appropriate.
9. C. The purpose of the salicylate therapy is to relieve the pain associated with the
migratory polyarthritis accompanying the rheumatic fever. Playing mini piano
would require movement of the child’s joints and would provide the nurse with a
means of evaluating the child’s level of pain.
10. D. The recommended position to administer rectal medications to children is side-
lying with the upper leg flexed. This position allows the nurse to safely and
effectively administer the medication while promoting comfort for the child.
11. C. For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe
to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s
(120).
12. B. Chest physiotherapy treatments are scheduled between meals to prevent
aspiration of stomach contents, because the child is placed in a variety of
positions during the treatment process.
13. C. It is common misconception that breastfeeding may prevent pregnancy.
14. B. The “security blanket” is an important transitional object for the toddler. It
provides a feeling of comfort and safety when the maternal figure is not present or
when in a new situation for which the toddler was not prepared. Virtually any
object (stuffed animal, doll, book etc) can become a security blanket for the
toddler.
15. D. Toddlers need to meet the developmental milestone of autonomy versus shame
and doubt. In order to accomplish this, the toddler must be able to explore and
manipulate the environment.
16. D. The introduction of a baby into a family with one or more children challenges
parent to promote acceptance of the baby by siblings. The parent’s attitudes
toward the arrival of the baby can set the stage for the other children’s reaction.
Spending time with the older siblings alone will also reassure them of their place
in the family, even though the older children will have to eventually assume new
positions within the family hierarchy.
17. D. The autonomous toddler would be frustrated by being confined to be. The
pounding board and hammer is developmentally appropriate and an excellent way
for the toddler to release frustration.
18. D. It is the developmental task of an 18-month-old toddler to explore and learn
about the environment. The respiratory complications associated with cystic
fibrosis (which are present in almost all children with cystic fibrosis) could
prevent this development task from occurring.
19. C. The best diversion for a hospitalized child aged 2-3 years old would be
anything that makes noise or makes a mess; xylophone which certainly makes
noise or music would be the best choice.
20. B. An 11-month-old child stands alone and can walk holding onto people or
objects. Therefore the installation of a gate at the top and bottom of any stairs in
the house is crucial for the child’s safety.
21. D. In second grade a child needs to form a close relationships with peers.
22. B. A 5-year-old is highly concerned with body integrity. The preschool-age child
normally asks many questions and in a situation such as this, could be expected to
ask even more.
23. C. A 9-year-old enjoys working and feeling a sense of accomplishment. The
school-age child also enjoys “showing off,” and doing something with the nurse
on the pediatric unit would allow this. This activity also provides the school-age
child a needed opportunity to interact with others in the absence of school and
personal friends.
24. B. Adolescents do feel indestructible, and this is reflected in many risk-taking
behaviors.
25. D. An 8-month-old infant both recognizes and is fearful of strangers. This
developmental milestone is known as “stranger anxiety”.
26. A. The basal body temperature (BBT) is the lowest body temperature of a healthy
person that is taken immediately after waking and before getting out of bed. The
BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about
5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05
degree Celsius in temperature may be seen; after ovulation, in concert with the
increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4
degree Celsius. This elevation remains until 2-3 days before menstruation, or if
pregnancy has occurred.
27. C. The woman must understand that, although the “fertile” period is
approximately midcycle, hormonal variations do occur and can result in early or
late ovulations. To be effective, the diaphragm should be inserted before every
intercourse.
28. D. Although instructions vary among birth centers, primigravidas should seek
care when regular contractions are felt about 5 minutes apart, becoming longer
and stronger.
29. B. Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication
during arousal.
30. B. A wood surface provides the least chance for organisms to be present.
31. A. Preventing infection in the infant with eczema is the nurse’s most important
goal. The infant with eczema is at high risk for infection due to numerous breaks
in the skin’s integrity. Intact skin is always the infant’s first line of defense
against infection.
32. B. A skin rash could indicate a concurrent infectious disease process in the
infant. The scheduled immunizations should be withheld until the status of the
infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in
skin integrity, and infectious-appearing secretions are indications to withhold
immunizations.
33. C. Continuity is essential to promote active immunity and give hepatitis B
lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the
first.
34. B. Because of the high incidence of breast cancer, all women are considered to be
at risk regardless of health history.
35. B. Handwashing is the best way to prevent the spread of infection.
36. A. The purpose of the visit takes priority.
37. D. Frequent douching interferes with the natural protective barriers in the vagina
that resist yeast infection and should be avoided.
38. A. Completion for the recommended schedule of infant immunizations does not
require a large number of immunizations, but it also provides protection against
multiple pediatric communicable and infectious diseases.
39. C. This is appropriate foods that are high in iron and calcium but would not affect
lactose intolerance.
40. D. Intervention is needed when the woman thinks that she needs to wait only 6
months after being free of TB before she can get pregnant. She needs to wait 1.5-
2years after she is declared to be free of TB before she should attempt pregnancy.
41. C. Salmonella organisms cause lower GI symptoms
42. C. It is a safety hazard to have shiny floors and scattered rugs because they can
cause falls and rugs should be removed.
43. C. Condoms do not prevent ALL forms of sexually transmitted diseases.
44. A. Pregnancy is one contraindication to breast-feeding. Milk secretion is
inhibited and the baby’s sucking may stimulate uterine contractions.
45. C. Perianal itching is the child’s chief complaint associated with the diagnosis of
pinworms. The itching, in this instance, is often described as being “intense” in
nature. Pinworms infestation usually occurs because the child is in the anus-to-
mouth stage of development (child uses the toilet, does not wash hands, places
hands and pinworm eggs in mouth). Teaching the child hand washing before
eating and after using the toilet can assist in breaking the cycle.
46. C. Severe itching of the scalp is the classic sign and symptom of head lice in a
child. In turn, this would lead to the nursing diagnosis of “altered comfort”.
47. C. Kernig’s sign is the inability of the child to extend the legs fully when lying
supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is
also present in bacterial meningitis and occurs when pain prevents the child from
touching the chin to the chest.
48. C. The primary goal is to prevent the spread of the disease to others. The child
should experience no complication. Although the health department may need to
be notified at some point, it is no the primary goal. It is also important to prevent
discomfort as much as possible.
49. A. Conjunctivitis is highly contagious. Antibiotic drops are usually administered
four times a day. When purulent discharge is present, saline eye irrigations or eye
applications of warm compresses may be necessary before instilling the
medication. Ophthalmic analgesic ointment or drops may be instilled, especially
at bedtime, because discomfort becomes more noticeable when the eyelids are
closed.
50. D. The question asks about the immediate concern. The ABCs of community
health care are always attending to people’s basic needs of food, shelter, and
clothing