Which treatment is appropriate for hemophilia?

Exercise
Corticosteroids
Pain management
Replacement of missing clotting factor
Rationale
Replacement of the missing clotting factor is the primary therapy for hemophilia. Exercise is
important but not the primary therapy for hemophilia. Corticosteroids are helpful for hematuria
and chronic synovitis but are not the primary therapy for hemophilia. Treatment of pain is
important but not the primary therapy for hemophilia.

A child is prescribed a buccal analgesic for pain relief. How should the nurse administer the drug
to the child?
Place the drug above the tongue.
Instruct the child to chew the drug.
Instruct the child to swallow the drug.
Place the drug between cheeks and gums.
Rationale
A transmucosal route of administration helps in rapid absorption of drug due to the rich blood
supply to the oral mucosa. The drug should be placed between cheeks and gums for proper
absorption through the oral mucosa. The drugs are placed under the tongue during buccal
administration of drug. A drug meant to be administered through the transmucosal route should
not be swallowed or chewed, because this can affect the therapeutic levels of the drug.

What is the current understanding for how biobehavioral interventions for pain management
work in children?
They make the pharmacologic strategies less effective.
They work faster than most pharmacologic strategies do.
They convince children that they are not experiencing pain.
They provide coping strategies that help reduce pain perception.
Rationale
Biobehavioral interventions provide children with coping strategies that may help reduce pain
perception. Biobehavioral interventions may enhance the effectiveness of pharmacologic
strategies rather than making them less effective. Biobehavioral interventions may take longer to
reduce pain perception than pharmacologic strategies do. Biobehavioral interventions do not
trick children into believing that they are not experiencing pain.

Which strategies are biobehavioral intervention for pain management? Select all that apply.
Select all that apply
Relaxation
Positive self-talk
Thought stopping
Behavioral contracting
Nonsteroidal antiinflammatory drugs (NSAIDs)
Rationale
Biobehavioral interventions tor pain management include use of relaxation, positive self-talk,
thought stopping, and behavioral contracting. Even though NSAIDs are not narcotics, they are
considered pharmacologic treatment.

The nurse is performing the pain assessment of a 6-year-old child with a developmental disorder.
The child has limited speech and lacks the ability to understand spoken words and sentences.
What tool does the nurse use to assess pain in the child?
FLACC scale
Poker Chip Tool
Visual Analog Scale
Word-Graphic Rating Scale
Rationale
The child has limited speech and moreover lacks the ability to understand sentences; therefore
the nurse has to assess the child's pain using a behavioral tool such as FLACC scale. The child
lacks the ability to understand what the nurse says, so the nurse cannot use the Poker Chip Tool
for pain assessment in the child. The child lacks the intelligence to understand the instructions
for using the Visual Analogue Scale or the Word-Graphic Rating Scale; therefore the nurse
cannot use these scales for assessing the pain in the child.

What would the nurse recognize as the most reliable indicator of pain in school-age children?
Crying
Verbal report
Increased heart rate
Increased blood pressure
Rationale
A verbal report of pain is the most reliable indicator of pain in school-age children. Crying,
increased heart rate, and increased blood pressure are not always indicative of pain but can be
complex responses to emotional stress.

What method of analgesia delivers a constant amount of analgesic and is best for possible
prevention of returning pain?
Regional nerve blocks
Nurse-administered boluses
Patient-administered boluses
Continuous basal-rate infusion
Rationale
Continuous basal-rate infusions deliver a constant amount of analgesic and are the best option to
prevent pain from returning. Patient-administered boluses are infused according to the preset
amount and lockout interval. Nurse-administered boluses are typically used to give an initial
loading dose to increase blood levels rapidly and to relieve breakthrough pain.

The nurse is caring for a child who needs continuous medications for pain control. Which
medication route for continuous analgesic administration proves to be most effective for
children?
Oral
Sublingual
Transmucosal
Intravenous (IV)
Rationale
IV route is the best route for administering pain medications because it enables the rapid control
of severe pain. The child may need rest and may not be able to take oral medications, and oral
medications do not provide rapid control of severe pain. Sublingual and transmucosal
medications have an increased risk of swallowing in small children.

The nurse is caring for a comatose child with multiple injuries. Which information about pain
would apply to this situation?
It cannot occur if a child is comatose.
It may occur if the child regains consciousness.
It requires astute nursing assessment and management.
It is best assessed by family members who are familiar with the child.
Rationale
Because the child cannot communicate pain through one of the standard pain-rating scales, the
nurse must focus on physiologic and behavioral manifestations to accurately assess the child’s
pain. Pain can occur in the comatose child. The family can provide insight into the child's
responses, but the nurse should be monitoring physiologic and behavioral manifestations.

A student nurse is attempting to use biobehavioral interventions for pain management for a child.
Which strategy used by the student nurse warrants the preceptor to further educate the student
nurse?
Consulting a child-life specialist
Involving the child in playing or singing
Telling the child, "This is going to hurt."
Staying with the child during a painful procedure
Rationale
Biobehavioral intervention for pain management for a child include avoidance of "planting" the
idea of pain. Therefore, the student nurse should be further educated about why the statement,
"This is going to hurt" to a child is incorrect. Effective biobehavioral interventions include
consulting a child-life specialist, involving the child in playing or singing, and being with the
child during painful procedures.

What is the best approach in managing pain in children?

Preventing the pain
Administering medications early
Providing medications as needed
Administering maximum dose of pain medications
Rationale
Prevention of pain is the best approach to pain management in children. Administering
medications early is not a good approach to pain management in children. Administering
medications as needed is not a good approach to pain management. Administering the minimum,
not the maximum, dose of pain medications is appropriate.
What age patient would a nurse use the FACES Pain Rating Scale for pain assessment?
1 year
2 years
3 years
4 years
Rationale
The FACES Pain Rating Scale can be used in children as young as 3 years. One or 2 years of age
is too young for the FACES scale. Four years old is not the youngest age for which the FACES
scale is appropriate.

A child who is terminally ill with bone cancer is in severe pain. Nursing interventions to increase
the pain mediation dosage would be based on which knowledge of cancer pain?
Children tend to be overmedicated for pain.
Giving large doses of opioids results in death.
Narcotic addiction is common in terminally ill children.
Large doses of opioids are justified when there are no other treatment options.
Rationale
Large doses of opioids may be needed because the child has become physiologically tolerant of
the drug, requiring higher doses to achieve the same degree of pain control. Pain is considered
the fifth vital sign, and management of pain is critical to treatment of a child with bone cancer.
Continuing studies report that children are consistently undermedicated for pain. The dosage of
opioids is titrated to relieve pain, not cause death. Addiction is a psychological dependence on
the narcotic medication, which does not occur in terminal care.

Which ethnic group has the highest incidence of sickle cell disease?
Whites
Hispanics
American Indians
African Americans

Which procedure is appropriate when identifying the means of eliminating excess iron in a child
with thalassemia major?
Antiemetics
Splenectomy
Chelation therapy
Blood transfusions
Rationale
Chelation therapy minimizes the development of hemosiderosis (iron overload), a complication
of blood transfusions. Antiemetics help ease nausea and vomiting. Splenectomy is necessary
when severe splenomegaly develops. Blood transfusions are the primary medical management.

Which process produces red blood cells?

Erthrocytosis
Leukocytosis
Polycythemia
Erythropoiesis
The nurse observes that the child’s usual dose of analgesic is unable to relieve pain in a 12-year-
old child with sickle cell anemia after 3 weeks. What does the nurse conclude from this finding?
The doses were not spaced efficiently.
The child has become addicted to analgesic.
The child has developed another complication.
The child has developed tolerance to analgesic.
Rationale
If the body gets adapted to the drug, the usual doses of the drug are unable to have the desired
effect. This is called tolerance to the drug. Development of other complications is evident from
fever, nausea, or other physical symptoms. Tolerance is caused by the neuroadaptation to the
effects of the drug, not by ineffective spacing of the drug. Addiction is indicated by
preoccupation with obtaining the drug and using it continually, even if there is adequate
analgesia.

Which combination therapy treatment method has improved the prognosis for children with HIV
infection?
Antibiotic
Analgesic
Antiemetic
Antiretroviral
Rationale
Combination antiretroviral therapy has greatly improved the prognosis for children with HIV
infection. Combination antibiotic therapy is not used to treat HIV. Combination analgesic
therapy has not improved the prognosis for children with HIV infection; nor has combination
antiemetic therapy.

The nurse observes increased irritability, nausea, diarrhea, sweating, and fever in a child on the
second day after discontinuing the opioid dose. What does the nurse conclude from the child's
condition?
The child is addicted to opioids.
The child is having withdrawal symptoms.
The child is displaying side effects of opioids.
The child is having a painful episode due to sickle-cell disease.
Rationale
Withdrawal symptoms such as increased irritability, nausea, diarrhea, sweating, and fever are
seen when an opioid is abruptly discontinued. This happens because the use of opioids causes
physical dependence. These need to be gradually weaned to avoid withdrawal symptoms. The
child is not addicted to opioids, but there is physical dependence on the drug. Painful episodes,
indicated by chest pain, enlarged spleen, and fever, are observed in children with sickle-cell
disease. Increased irritability, nausea, diarrhea, sweating, and fever are not side effects of opioids
but are withdrawal symptoms.

The nurse is caring for a child with a cognitive impairment who is postoperative. Which pain
assessment scale does the nurse use for recording the vital signs of the child?
Pain Assessment Tool
Postoperative Pain Score
Neonatal Infant Pain Scale
Non-Communicating Children's Pain Checklist
Rationale
The Non-Communicating Children's Pain Checklist is a pain assessment scale developed for
children with cognitive impairment. Cognitive impairment includes impaired vision, hearing, and
speech. The assessment involves physiologic and behavioral signs and is scored from zero to 10
in a time period of 10 minutes. The Postoperative Pain Score, Pain Assessment Tool, and
Neonatal Infant Pain Scale are not used for children with impaired senses. These tools are used
for assessing pain in normal individuals

Which chance is appropriate for a woman with sickle cell anemia (SCA) and her husband
without the condition to have a child with sickle cell anemia?
0% chance that their children will have SCA
25% chance that male children will have SCA
50% chance that female children will have SCA
100% chance that their children will have SCA
Rationale
Sickle cell anemia is an autosomal recessive disorder. Therefore, both male and female children
can be affected. In this scenario no one will be affected with SCA, because the father is normal.
All of their children will be carriers of SCA, because the mother has SCA. If both parents are
carriers of sickle cell anemia, there is a 25% chance that their children will be affected, a 25%
chance that their children will be normal, and a 50% chance that their children will be carriers of
the abnormal gene. If one of the parents is a carrier and the other parent is normal, there is a 50%
chance that their children will be carriers and a 50% chance that their children will be normal.

A child who has been receiving intravenous (IV) morphine will now start receiving the
medication orally. For equianalgesia to be achieved, what how should the oral dose compare to
the IV dose?
Same as the IV dose
One-half of the IV dose
Greater than the IV dose
One-fourth of the IV dose
Rationale
When the route of morphine administration is changed from IV to PO (by mouth), it is essential
that the dose be increased to produce an equianalgesic effect. Oral morphine is not as effective at
the same dose as IV morphine. The dosage of morphine is increased, not decreased, when the
administration route changes from IV to PO.

Which blood coagulation factor abnormality can be determined using only the prothrombin time
(PT) rather than using both the PT and the partial thromboplastin time (PTT)?
Factor II
Factor V
Factor VII
Factor X
Rationale
Abnormalities of factor VII can be measured by determining the prothrombin time (PT) rather
than the partial thromboplastin time (PTT). The PT measures the activity of prothrombin and the
factors necessary for its conversion to thrombin and fibrinogen. It measures abnormalities of the
extrinsic pathway. Abnormalities of factor VII cannot be determined by the PTT, which
measures abnormalities of the intrinsic pathway. Abnormalities of factors II, V, and X can be
determined by both PT and PTT, because these factors are involved both in the intrinsic and
extrinsic pathways.

What is the most commonly used behavioral pain measurement tool in children?
Numeric Scale
Visual Analog Scale
Word-Graphic Rating Scale
FLACC Pain Assessment Tool
Rationale
The FLACC Pain Assessment Tool is the most commonly used behavioral pain measure. The
Word-Graphic Rating Scale, Visual Analog Scale, and the Numeric scale are not behavioral pain
measurement tools.

The nurse is assessing a 4-year-old child for pain on admission assessment. What assessment
tool does the nurse use for this patient?
Faces pain scale
Numerical rating scale
Pain Assessment Tool
Postoperative Pain Score
Rationale
The nurse uses a faces pain scale, which shows a series of facial expressions depicting the
degrees of pain. The child can easily point at the face that represents how the child is feeling.
The numerical rating scale is used for children more than 8 years old, whereby the child can rate
the intensity of pain on a scale of zero to 10. The Pain Assessment Tool is used to examine pain
in infants. The Postoperative Pain Score is used for testing postoperative pain in infants less than
7 months old.

What way is chronic pain different from recurrent pain in children?

Chronic pain is episodic and reoccurs.
Chronic pain persists for 3 months or more.
Anxiety is elevated in children with chronic pain.
Depression is elevated in children with recurrent pain.
Rationale
Pain that persists for 3 months or more is known as chronic pain. Recurrent pain is pain that is
episodic and reoccurs at intervals. Chronic pain is not episodic. It persists for extended periods of
time. Anxiety and depression are elevated in children with chronic as well as recurrent pain,
because the pain may interfere with the child’s normal functioning.

Which finding is appropriate when assessing a microscopic study of red blood cell (RBC)
morphology as a sign of sickle cell anemia (SCA)?
Spherocytes
Drepanocytes
Normocytes
Macrocytes
Rationale
The presence of drepanocytes or sickle-shaped cells indicates SCA. The abnormal adhesion,
entanglement, and enmeshing of rigid sickle-shaped cells accompanied by the inflammatory
process intermittently blocks the microcirculation causing vasoocclusion. RBCs that are globular
in shape are called spherocytes. Normocytes are RBCs with normal cells. Macrocytes are RBCs
that are larger than normal in size.

Which factor is appropriate to consider when administering iron?

To administer with ascorbic acid
Can be given into a small muscle
May be mixed with yogurt for administration to small children
Would be injected deeply into a large muscle mass using an air-lock method
Rationale
Iron should be given with ascorbic acid (Vitamin C). Iron would be given into large muscles to
prevent skin staining and irritation. Iron would be injected deeply into a large muscle with the Z-
track, not the air-lock, method to prevent skin staining and irritation.

A child is being seen in the emergency department with multiple facial abrasions and lacerations.
The combination agent lidocaine, adrenaline, and tetracaine (LAT) is applied topically to the
wounds. What is the purpose of this combination therapy?
To cleanse the wound
To promote scab formation
To prevent infection of the wound
To provide anesthesia for the wound
Rationale
The combination of lidocaine, adrenaline, and tetracaine provides anesthesia within 10 to 15
minutes of application. LAT does not have a cleansing or antibacterial effect, nor does it have an
effect on scab formation.

What is the most consistent indicator of pain in infants?

Increased heart rate
Squirming and jerking
Quickened respiration
Facial expression of pain
Rationale
A facial expression of pain is the most consistent indicator of pain in infants. Increased heart rate
may or may not be a symptom of pain in infants. Squirming and jerking are common in infants
with and without pain. An increased rate of respiration may or may not be a symptom of pain in
infants.

Which hematologic disorder is common in infancy and childhood?

Anemia
Leukemia
Immune thrombocytopenia
Disseminated intravascular coagulation
Rationale
Anemia is the most common hematologic disorder of infancy and childhood. Leukemia is a
neoplastic disorder. Immune thrombocytopenia and disseminated intravascular coagulation are
hematologic disorders that are less common than anemia.

Which nursing response is appropriate for the parents of a child with sickle cell anemia that are
concerned about subsequent children having the disease?
"Sickle cell anemia is not inherited."
"All siblings will have sickle cell anemia."
"There is a 25% chance of a sibling having sickle cell anemia."
"There is a 50% chance of a sibling having sickle cell anemia."
Rationale
Sickle cell anemia (SCA) is inherited as an autosomal recessive disorder. In this inheritance
pattern there is a 25% chance that each subsequent child will have the disorder. SCA is an
inherited hemoglobinopathy. In autosomal recessive disorders there is a chance that 25% of the
children will have neither SCA nor the sickle cell trait. There is a chance that 50% of the siblings
will have the sickle cell trait.

Which HIV test is appropriate when diagnosing a 2-month-old child born to an HIV-infected
mother?
CD4 lymphocyte count
Western blot immunoassay
The HIV enzyme-linked immunosorbent assay (ELISA)
The HIV polymerase chain reaction test for detection of proviral DNA
Rationale
The HIV polymerase chain reaction test for detection of proviral DNA is used to diagnose
infants as young as 1 to 6 months old. CD4 lymphocyte counts categorize HIV. Because
maternal antibodies may persist in the infant for up to 18 months, the Western blot immunoassay
and the HIV enzyme-linked immunosorbent assay (ELISA) are only used for infants 18 months
of age and older.

Which clinical manifestations are appropriate for an HIV infection in children? Select all that
apply.
Weight gain
Oral candidiasis
Chronic diarrhea
Lymphadenopathy
Developmental delay
Rationale
Common clinical manifestations of HIV infection in children include oral candidiasis,
developmental delay, chronic diarrhea, and lymphadenopathy. Weight gain is not a common
clinical manifestation of HIV infection in children.

Which method is an appropriate way to stop an occasional episode of epistaxis?

Having the child sit up and lean forward
Applying ice under the nose and above the lip
Having the child lie down quietly with the feet elevated
Applying continuous pressure to the nose with the thumb and forefinger for 1 minute
Rationale
Having the child sit up and lean forward is the intervention used to prevent the child from
aspirating blood. Pressure, not ice, is indicated for an occasional episode of epistaxis. Having the
child lie with the feet elevated could lead to aspiration. Continuous pressure for 10 minutes is
recommended; one minute would not be long enough.

The nurse is teaching a group of nursing students alternate versions of pain assessment scales for
children who do not speak English. Which pain assessment scale is available in alternate
versions?
Pain Rating Scale
Scale for Use in Newborns
Adolescent Pediatric Pain Tool
Non-Communicating Children's Pain Checklist
Rationale
For effective management of pain of non–English-speaking children, the Adolescent Pediatric
Pain Tool may be given to the child. Encourage the child to use the diagram for communicating
the location and extensiveness of pain. The Pain Rating Scale, the Scale for Use in Newborns,
and the Non-Communicating Children's Pain Checklist are available only in English and are not
effective for use with non–English-speaking children.

The nurse is teaching a group of school-age children about pain management. Which teaching
strategy should the nurse use to educate the children?
Incorporate their parents in the teaching.
Provide the children with medical journals and articles to read.
Educate using interactive audio and visual aids with the children.
Get assistance from primary health care provider to review information.
Rationale
Prior education of children about pain management strategies is important for effective pain
management. School-age children can be educated with the help of an interactive session in
which the instructions are recorded and played. Assistance from parents may not promote
learning in children. Children may not be interested in reading medical journals. Assistance from
a health care provider may not be helpful in promoting learning in children.

The nurse is working with a child who is cognitively impaired and unable to verbalize pain.
Which pain scale is appropriate for use with this patient?
Numeric Pain Rating Scales
Neonatal Infant Pain Scale (NIPS)
Non-communicating Children’s Pain Checklist
Facial expression, Leg movement, Activity, Cry, and Consolability (FLACC)
Rationale
Children with cognitive impairment may be assessed by the Non-communicating Children's Pain
Checklist, which is one of three validated tools for use with cognitively impaired children.
Numeric scales require the child to understand and rate pain. FLACC is used to assess behavior,
yet is not standardized to use with children who have cognitive impairment. NIPS is used for
neonates and/or infants.

The nurse is preparing an 8-year-old child for a subcutaneous injection. Which statement by the
nurse is most effective?
"I promise that it is going to hurt just a little bit."
"This is terrible, but I know you are very strong."
"It feels like burning pain, but it goes away soon."
"It may feel like pinching. You tell me how it feels."
Rationale
The nurse prepares the child by saying that the injection may "feel like pinching" so that the
child is not anxious or scared. Telling the child that it is going to hurt just a little may make the
child scared. If the nurse says that it feels like burning pain, the child perceives it as threatening.
Instead the nurse can say that it feels like heat. Using evaluative statements such as "this is
terrible" increases the child's anxiety.

The nurse is assessing a 10-year-old child with recurrent headaches. Which questions does the
nurse ask the parents to assist in gathering assessment information for identifying the cause of
the headaches? Select all that apply.
Select all that apply
"Tell me about your child's school-related work."
"What kind of medications is your child taking?"
"How often does your child complain of headache?"
"What kind of outdoor games does your child prefer?"
"When was the last time your child visited an ophthalmologist?"
Rationale
Tension, medications, and weakness of the eye muscles are some of the factors that may cause
headaches. The nurse can assess whether the child experiences tension related to school or peer
relationships. Drug history helps to assess whether any medications are causing headaches.
Information about visits to an ophthalmologist helps the nurse to assess whether the child has eye
problems that may be causing headaches. The nurse can also assess the nature of the headache by
asking the patient to describe it. Asking about outdoor games is more relevant for assessing the
physical activity of the child.

A nurse is administering a hepatitis B vaccine to a 1-year-old child. Which nursing intervention

would the nurse refrain from doing in order to reduce injection pain?
Placing the child in the supine position
Using topical anesthesia prior to injection
Administering the injection rapidly without aspiration
Using proper injection site and needle size based on the age of the child
Rationale
The nurse should place the child in an upright position. The supine position causes increased
fear, which may make the child cry and can increase pain. Using topical anesthesia,
administering the injection rapidly without aspiration, and using a proper injection site and
needle size will help in reducing pain during injection.
Nurses working with children need to be aware that children with unrelieved severe pain may
engage in certain behaviors. What behavior would the nurse expect to encounter in a child
experiencing severe unrelieved pain?
Addiction
Increase in appetite
Mental clarity and alertness
Frequent checking of the clock
Rationale
Frequently checking the clock is common in a patient suffering from severe unrelieved pain.
They may appear to others to be preoccupied with getting more opioids, but the preoccupation is
actually focused on finding relief of the pain. Pseudoaddiction, rather than addiction, is a
behavior that the nurse can expect to encounter in a child experiencing severe unrelieved pain. A
decrease in appetite, rather than an increase in appetite, is more likely to occur. Mental clouding,
rather than mental clarity, is to be expected.

The nurse is assessing pain in a 7-year-old child with cognitive impairment and communication
difficulties. Which sign does the nurse observe for pain in this child?
Moaning
Rapid talking
Fist clenching
Sleeping often
Rationale
Moaning is an indication of pain experienced by a child with cognitive impairment. Children
with pain interact and speak less instead of talking rapidly. Children with pain sleep less, because
they are uncomfortable. Fist clenching is observed in infants who experience pain.

A nurse is caring for a child who is scheduled to undergo placement of an intravenous line for
chemotherapy. Which statement made by the nurse is helpful to change the child’s perspective of
pain before the procedure?
"It is a burning pain."
"It will not really hurt."
"It really will hurt a lot."
"Sometimes it feels like pinching."
Rationale
The nurse should prepare the child before painful procedures. The nurse should refrain from
planting the idea of pain in the child’s mind. The nurse should use consoling sentences such as,
" It may feel like a pinch," instead of saying the procedure will hurt. The nurse should evade
using evaluating sentences such as, "It will really hurt." The nurse should use nonpain
descriptors such as, "It feels like heat," instead of "It is a burning pain." The nurse should refrain
from using evaluating and subjective sentences such as, "It really will hurt a lot." The nurse
should be honest about pain to establish trust.

The nurse recognizes that an important part of palliative care is decision making at the end of
life. What ethical dilemma might the nurse encounter in end-of-life care?
Questions about possible curative treatment
Discussion of euthanasia with family and child
Plans for long-term goals with the family and child
Issues of how to restore the child to normal function
Rationale
Nurses encounter many ethical dilemmas in end-of-life care, including euthanasia, assisted
suicide, and do-not-resuscitate orders. Issues related to curative treatment and normal function
are not ethical dilemmas for end-of-life care. Setting long-term goals for the child and family is
not an ethical dilemma that the nurse commonly encounters in end-of-life care.

A nurse is starting an intravenous (IV) line for a school-age child with cancer. The child says,
"I've had a million IVs. They hurt." How the nurse responds would be based on which pain
principle?
Children tolerate pain better than adults who are undergoing treatment for similar chronic
illnesses.
Children often lie about experiencing pain to avoid negative opinions from caregivers and health
care providers.
Children become accustomed to painful procedures over time, especially with chronic illnesses.
Children often demonstrate increased behavioral signs of discomfort with repeated painful
procedures.
Rationale
Children with chronic illnesses are more likely to identify invasive procedures as stressful than
are children with acute illnesses. There are no data to support the theory that children tolerate
pain better than adults. The child has increasing difficulty with numerous and repeated painful
procedures rather than becoming accustomed to them. Pain is subjective.

A school-age child is brought to the hospital after falling while riding a bike. The child has a
swollen knee and is in pain with assessment. The nurse anticipates that which medication will be
prescribed by the primary health care provider?
Fentanyl
Morphine
Naproxen
Methadone
Rationale
The primary health care provider gives naproxen to the child, because the child has developed
inflammation in the knee. Naproxen is a nonsteroidal antiinflammatory drug. Fentanyl,
morphine, and methadone are opioid drugs. They are prescribed for children with severe pain.

A nurse working with an infant in the neonatal intensive care unit and is observing the infant for
pain. What are the initial signs of pain anticipated in the neonate? Select all that apply.
Changes in activity
Change in temperature
Changes in consolability
Changes in blood pressure
Changes in facial expression
Rationale
Behavioral assessment is used for assessing the intensity of pain in infants. Because infants lack
verbal communication, behavioral assessment is important in the management of care. The initial
indication of pain in infants is a change in facial expression. The next behavioral assessments
that indicate pain are changes in activity and changes in consolability. Changes in blood pressure
and temperature are physiologic assessments in the management of care for infants.

A nurse is assessing the pain of a child using the FACES pain rating scale. The child picked the
second face 2 hours earlier. The child chooses the fourth face when asked how the pain feels
now. What does the nurse interpret from the face the child has chosen?
Pain hurts a little bit.
Pain hurts a whole lot.
Pain hurts even more.
Pain hurts a little more.
Rationale
The nurse interprets that the pain score of the child is four, which means that it hurts even more.
A score of one is given if the pain hurts a little bit. A score of four is given if the pain hurts a
whole lot. A score of two is given if the pain hurts a little more.

What are some of the most common side effects of opioid analgesics? Select all that apply.
Sedation
Mania
Constipation
Nausea and vomiting
Respiratory depression
Rationale
Sedation, constipation, nausea and vomiting, and respiratory depression are common side effects
of opioids. Addiction is not a common side effect of opioids because the risk of addiction with
opioids is low. The NIH website and drug abuse website ( www.drugabuse.gov) both state the
risk of addiction with opioids is increasing in the United States. Opioids are central nervous
system depressants, not stimulants. Mania is more likely to occur with stimulant use.

A child who is treated with morphine for cancer-related pain develops tolerance to the drug.
Which intervention is performed to treat tolerance in the child?
Increase the dose of the drug.
Increase the duration between doses.
Administer an adjuvant to morphine.
Administer an antagonist to morphine.
Rationale
Clients treated with morphine may develop tolerance to the drug if administered for 3 weeks or
more. As a result, the client may not experience the same therapeutic effect. To treat tolerance,
the dose of the drug should be increased to achieve the desired pain relief. Another way is to
decrease the duration between the doses, so that the therapeutic effect does not subside.
Administering an adjuvant or an antagonist may not bring about the desired pain relief.
The nurse is teaching pain management strategies to the parents of a 6-year-old child with
recurrent abdominal pain. The nurse instructs the parents to avoid giving excessive attention to
the child's abdominal pain. What is the purpose of this advice?
To help the child learn to deal with the pain
To teach the child not to complain about pain
To make the child feel comfortable with the pain
To prevent positive reinforcement of the sick behavior
Rationale
The nurse tells the parents to employ cognitive-behavioral strategy in which the parents avoid
paying excessive attention to the pain. Instead the parents reward the healthy behavior of the
child. This helps the child to modify the sick behavior and demand less attention. The strategy is
not to prevent the child from complaining but to avoid paying special attention to it. The child is
taught self-control skills to feel comfortable about the pain and to deal with it effectively.

The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive
care unit (NICU). What is included as a component in this tool?
Color
Reflexes
Oxygen saturation
Posture of extremities
Rationale
The components of the scale are C crying, R requires increased oxygen, I increased vital
signs, E expression, and S sleepless. Changes in oxygen saturation would affect scoring. Color is
not a component of this scale; neither are reflexes nor posture of the arms and legs.

A nurse is caring for a 5-year-old child who has a new order for the insertion of an intravenous
line. What intervention will be the most effective way of providing analgesia before this
procedure?
Place a transdermal fentanyl (Duragesic) patch at the site of venipuncture.
Use lidocaine-tetracaine for 20 minutes at the site for the intravenous line.
Administer lidocaine-adrenaline-tetracaine (LAT) 15 minutes before the procedure.
Apply a eutectic mixture of local anesthetics (EMLA) immediately before the procedure for 5
minutes at the site.
Rationale
Lidocaine-tetracaine is an effective analgesic agent when applied to the skin 1 hour before a
procedure. It eliminates or reduces the pain of most procedures involving skin puncture.
Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.
EMLA needs to be applied 60 minutes before the procedure to be effective. LAT gel is used to
numb areas for sutures or staples, not for venipuncture.

The nurse is assessing pain in a 3-month-old infant. Which physiologic signs indicate acute pain
in the infant? Select all that apply.
Dilated pupils
Pallor or flushing
Decreased heart rate
Increased muscle tone
Rapid, shallow respirations
Rationale
Increased muscle tone, pallor or flushing, rapid, shallow respirations, and dilated pupils indicate
that the infant experiences acute pain. Acute pain is indicated by increased heart rate, not
decreased heart rate.

Which are physiologic manifestations of acute pain in the neonate? Select all that apply.
Diaphoresis
Pinpoint pupils
Palmar sweating
Decreased heart rate
Decreased arterial oxygen saturation
Rationale
Physiologic manifestations of acute pain in the neonate include diaphoresis, palmar sweating,
and decreased arterial oxygen saturation. Dilated pupils (not pinpoint) and increased, rather than
decreased, heart rate are manifestations of acute pain in the neonate.

The nurse observes that a 13-year-old child with sickle-cell anemia engages in manipulative
behavior, is preoccupied with obtaining the opioid, and persistently asks for more analgesic.
What can the nurse conclude from this behavior?
The child is getting addicted to analgesic.
The child is having withdrawal symptoms.
The child has developed clock-watching behavior.
The child has developed physical dependence on analgesic.
Rationale
Patients with sickle-cell anemia have been dealing with pain for a long time and are
knowledgeable about pain medication and doses. Therefore there is a possibility of
developing tolerance to the drug. This makes the patient ask for increased doses or get
preoccupied with obtaining medication. This behavior is called clock-watching behavior.
Addiction refers to the loss of control over the use of medications. The patient is preoccupied
with obtaining medication, even if there is adequate analgesia. Withdrawal symptoms, indicated
by fever, increased irritability, vomiting, diarrhea, and other dysfunctions, are caused when
opioids are discontinued abruptly. Physical dependence is a condition in which the abrupt
cessation of opioids causes withdrawal symptoms.

Transdermal fentanyl is being used for an adolescent with cancer who is in hospice care. The
adolescent has been comfortable for several hours but now complains of severe pain. What is
the most appropriate nursing action?
Using a biobehavioral intervention
Administering meperidine (Demerol) intramuscularly
Placing another fentanyl (Duragesic) patch on the adolescent
Administering morphine sulfate immediate release (MSIR) intravenously
Rationale
The nurse should administer an immediate-release opioid, such as MSIR, intravenously for the
breakthrough pain. Intramuscular (IM) injections should be avoided in cancer patients because of
the increased risk of bleeding and the fact that IM injections do not take effect immediately.
Biobehavioral interventions will not be effective in easing severe pain. Transdermal fentanyl will
take as long as 24 hours to reach its peak effect and therefore is not effective against severe
breakthrough pain.

A primary health care provider has ordered ibuprofen for a 1-year-old child. What is the
maximum advised dosage of the drug that can be administered in a day?
1250 mg/day
3000 mg/day
3200 mg/day
4000 mg/day

Which diagnosis in children would indicate the child may have significant difficulties in
communicating with others about pain? Select all that apply.
Select all that apply
Diabetes
Hearing loss
Cerebral palsy
Severe brain injury
Heavily sedated child

The nurse is caring for a child who had been on opioid medications for more than one week.
What initial signs of withdrawal does the nurse monitor for in the child? Select all that apply.
Select all that apply
Yawning
Rhinorrhea
Anaphylaxis
Constipation
Hallucinations

The nurse is given an order to administer an analgesic via the oral route to a 7-year-old child
postoperatively. The nurse observes that the child is unable to take the medication orally. The
provider changes the route to intravenous (IV) administration. Which nursing action first ensures
that the medication is administered safely?
The nurse uses a conversion table to calculate the dose.
The nurse documents the change of route in the records.
The nurse administers the dose as prescribed in the original order.
The nurse confirms the medication may be administered intravenously.

Which components are evaluated in the FLACC Pain Assessment Tool? Select all that apply.
Select all that apply
Cry
Activity
Consolability
Leg movement
Chest movement
Facial expression
Why are physiologic measurements in the assessment of pain in children not as useful as other
measurements of pain?
Children tend to underestimate pain.
Parental report of children's pain is more reliable than physiologic measurements.
The same physiologic signs that suggest fear, anxiety, or anger can also indicate pain.
Physiologic measurements are of limited value in assessing pain when the child is hospitalized.

A child who has been receiving intravenous (IV) morphine is switched to oral morphine. What
would the nurse understand about this change in the treatment plan when converting from IV to
oral morphine?
The dose will be half the intravenous dose.
The dose will be a fourth of the intravenous dose.
The dose will be the same as the intravenous dose.
The dose will be greater than the intravenous dose.

A nurse is caring for an 8-year-old child who has undergone surgery for multiple fractures and
other trauma from a motor vehicle injury. The child is experiencing severe pain. What is an
important consideration in the management of the child's pain?
Giving only an opioid analgesic at this time
Planning a preventive schedule of pain medication around the clock
Increasing the dosage of analgesic until the child is adequately sedated
Giving the child a clock and explaining when the child may have pain medications
Rationale
An around-the-clock administration strategy should be used for a child recovering from trauma
and surgery. This schedule will help prevent a low plasma level of the drug, which could result
in breakthrough pain. It is appropriate for the immediate concern of the child's pain to give an
opioid analgesic, but this will not facilitate the more long-term plan of pain management. The
dosage of analgesic is increased until the pain is controlled, not until sedation is adequate. The
child should be frequently assessed for pain and doses titrated accordingly. It is inappropriate to
give a child a clock with instructions for when pain medication may be given, especially a child
who has experienced a traumatic event.

A primary health care provider has ordered oxycodone as pain management for a 16-year-old
with chronic pain from an injury. What is the route of administration of the drug?
Oral
Intravenous infusion
Intravenous injection
Subcutaneous infusion

A child indicates "worst possible pain" on the Word-Graphic Rating Scale. What medication
is most appropriate to be ordered for the child as a substitute for morphine?
Ibuprofen
Meperidine
Acetaminophen
Hydromorphone
Rationale
The Word-Graphic Rating Scale is a pain assessment technique used in children of the age group
4 years to 17 years. "Worst possible pain" has a score of 10 on the scale and can be treated by
hydromorphone (Dilaudid), an effective substitute for morphine. Ibuprofen and acetaminophen
are used to treat mild pain in children. Meperidine is not the drug of choice, because it is
associated with many side effects.

A child with a burn over 30% of the body surface area is scheduled for a dressing change. What
analgesics are used for this child before the procedure is initiated?
Morphine
Ketamine
Fentanyl
Lorazepam
Rationale
The type of analgesia depends on the duration of the painful procedure. A dressing change for a
major burn injury is a long and painful procedure. Therefore, morphine is the preferred analgesic
agent, because it provides adequate pain-relieving effect for the procedure. Ketamine is used as a
premedication for a less painful procedure. Fentanyl is used for short procedures due to its short
duration of action. Lorazepam is used for reducing anxiety and does not reduce pain.

Chapter 28
Which nursing response is appropriate for the parent of a 2-month-old formula-fed baby that has
been advised by a friend to give fresh cow's milk to the baby instead of formula milk because it
has high nutritional value?
Fresh cow's milk is the best source of nutrition for a 2-month-old baby.
The mother can start giving cow's milk to her baby at 3 months of age.
Cow's milk should be avoided before 12 months of age, because it may cause sickle cell anemia.
Cow's milk should be avoided before 12 months of age, because it may cause iron-deficiency
anemia.
Rationale
It is important for a nurse to educate the parents about appropriate measures to be taken to
prevent iron-deficiency anemia. Fresh cow's milk contains a heat-labile protein that can induce
gastrointestinal bleeding in children younger than 12 months. It can also cause gastrointestinal
mucosal damage in these children, leading to bleeding. Therefore, fresh cow's milk should not be
given to children before 12 months of age, because it may cause iron-deficiency anemia due to
gastrointestinal bleeding. Sickle cell anemia is not caused by cow's milk; instead, it is an
inherited genetic disease.

Which focus is appropriate when teaching the parents of a child whose laboratory results show
an absolute neutrophil count of less than 500/mm 3?
Administering iron supplements
Administering folate supplements
Preventing infection
Preparing the child for blood transfusion
Rationale
An absolute neutrophil count less than 500/mm 3 makes the child susceptible to infection. In this
condition, all efforts are made to prevent the child from contracting an infection. Iron and folate
supplements are required only if the child is suffering from iron deficiency anemia. This
condition does not commonly require a blood transfusion.

Which test is appropriate for the child with stiffness, tingling, and aches in the knee joints and
has a tendency toward prolonged bleeding?
Bleeding time
Tourniquet test
Clot retraction time
Partial thromboplastin time
Rationale
The symptoms hint that the child may be suffering from hemophilia. In hemophilia, factor VIII,
an intrinsic clotting factor, is deficient. Partial thromboplastin time measures the activity of
thromboplastin, which depends on intrinsic clotting factors. The partial thromboplastin time is
increased in hemophilia. Bleeding time reflects platelet function, which is normal in hemophilia.
The tourniquet test measures platelet function and capillary fragility, which are normal in
hemophilia. The clot retraction test measures the degree to which a clot shrinks, and it is usually
normal in hemophilia.

Which nursing action is appropriate during a blood transfusion, when a child reports mild
precordial pain?
Administer antihistamine.
Transfuse the blood slower.
Increase the rate of transfusion.
Administer epinephrine immediately.
Rationale
During a blood transfusion, it is the responsibility of a nurse to monitor the patient regularly to
look for any adverse effects. Precordial pain indicates that the child has circulatory overload, and
therefore the nurse would slow down the rate of transfusion. If this does not relieve the
symptoms, the nurse should stop the transfusion. Antihistamines are administered
prophylactically to a patient who tends to have allergic reactions. If a patient has asthmatic
wheezing during a blood transfusion, epinephrine should be administered.

Which nursing advice is appropriate for the parents of an 8-week-old baby with sickle cell
disease that does not want penicillin prophylaxis? Select all that apply.
"Penicillin prophylaxis is not required to be taken by all children with sickle cell disease."
"Children with sickle cell disease should take penicillin prophylaxis by 2 months of age."
"Penicillin prophylaxis should not be started before age 2."
"If a baby is put on penicillin, medical advice is not needed, even if the temperature exceeds
38.3°C."
"If a baby is put on penicillin, medical advice is needed if the temperature exceeds 38.3°C."
Rationale
It is the responsibility of a nurse to emphasize the importance of administering penicillin
prophylaxis to all children with sickle cell disease from the age of 2 months. These children are
at an increased risk of pneumococcal infections, and there is strong evidence indicating that
penicillin prophylaxis reduces the incidence of such infections. However, parents should be
advised to seek medical attention immediately if their child's temperature exceeds 38.3°C, even
if the child is on prophylactic treatment.

Which nursing response is appropriate when asked what deferoxamine is from the parents of a
child with β-thalassemia that is receiving numerous blood transfusions and deferoxamine
therapy?
"The medication helps prevent iron overload."
"The medication provides vitamin supplementation."
"The medication stimulates red blood cell production."
"The medication helps prevent blood transfusion reactions."
Rationale
A common side effect of hypertransfusion therapy is iron overload. Deferoxamine is an iron-
chelating drug that binds excess iron and allows it to be excreted by the kidneys. Deferoxamine
is not a vitamin supplement; nor does it stimulate red blood cell production or prevent
transfusion reactions.

Which method is appropriate when injecting parenteral iron preparations?

Injection into the deltoid muscle
Injection into a large muscle with the use of the Z-track method
Injection into a large muscle with the use of the air-lock method
Injection into a large muscle followed by massage to increase absorption
Rationale
The best way to administer parenteral iron preparations is injecting the medication into a large
muscle with the use of the Z-track method. Never inject iron into the deltoid muscle. It is not
appropriate to massage the site after injection of iron because this may worsen skin staining and
irritation. When iron is being injected into the muscle, the Z-track method is preferred over the
air-lock method.

Which statement is appropriate when explaining the significance of white blood cells to a 10-
year-old patient?
They help in phagocytizing bacteria.
White blood cells help keep germs from causing infections.
They give immunity against bacterial infections.
White blood cells carry oxygen from the lungs to all parts of the body.
Rationale
It is important for a nurse to avoid using medical jargon when talking to children. She would
explain medical terms in simple words that a child easily understands. Therefore the most
appropriate response of the nurse is to say that white blood cells help keep germs from causing
infections. Although it is correct that white blood cells help in phagocytizing bacteria and give
immunity against bacterial infections, these sentences contain medical jargon that is difficult for
a child to understand. It is the function of red blood cells, not white blood cells, to carry oxygen
from the lungs to all parts of the body.

Which nursing instruction is appropriate for the child diagnosed with iron-deficiency anemia and
is being treated with iron supplements that cause vomiting after ingestion? Select all that apply.
Increase the dosage of iron.
Give iron supplements with meals.
Give iron supplements with milk.
Avoid giving iron supplements with meals or with milk.
Decrease dose and then increase to ordered dose as tolerated.
Rationale
Vomiting and diarrhea sometimes occur when a child is given iron supplements. In such cases
the nurse should advise the parents to give iron supplements with meals. The dose of iron
supplements should also be decreased and then gradually increased until more tolerable. Milk
reduces the absorption of iron; therefore, iron should not be given with milk or milk products.

Which nursing instruction is appropriate for the 4-year-old child that is prescribed liquid iron for
iron-deficiency anemia? Select all that apply.
Give the iron using a straw.
Give the iron using a tablespoon.
Brush the child's teeth after administration of iron.
Brush the child's teeth before administration of iron.
Give iron along with milk or milk products.
Rationale
It is important for a nurse to inform the parents that giving iron in liquid form can stain the teeth.
Therefore it would be administered using a straw. Brushing the teeth after administration of iron
can prevent discoloration of teeth. Iron would not be given using a tablespoon, because it can
stain the teeth. Brushing the teeth before liquid iron administration has no effect on the staining
of the teeth. Cow's milk contains substances that interfere with iron absorption. Therefore, iron
would never be given along with milk or milk products.

Which response is appropriate for the parent of a child with sickle cell disease that is concerned
her child is becoming addicted to opioid?
"I hear your concern. Would you like to talk to an addiction specialist?"
"Your child is at high risk for becoming behaviorally addicted to opioids."
"It doesn't matter whether your child becomes addicted to opioids—the pain must be managed!"
"Very few children who are prescribed opioids for severe pain become behaviorally addicted to
the drugs."
Rationale
According to the American Pain Society and National Institutes of Health, very few children
who receive opioids for severe pain become behaviorally addicted to the drug. There is no need
for the nurse to have the parent speak to an addiction specialist unless the parent has continuing
concerns about the issue. Telling the parent that the child is at high risk for becoming
behaviorally addicted to opioids is not appropriate. Saying that it doesn't matter if the child
becomes addicted because the pain must be treated is not appropriate because it negates the
parent's concerns.

Which nursing intervention is appropriate for a child who develops a severe vasoocclusive
crisis?
Administration of analgesic to relieve pain
Application of cold compress to the affected area
Administration of oxygen to reverse sickled red blood cells
Administration of prophylactic antibiotics to prevent infection
Rationale
Vasoocclusive crisis is a very painful condition. The first effort should be to relieve pain.
Applying a cold compress to the affected area enhances vasoconstriction and occlusion, thereby
aggravating the situation. Oxygen administration is not very beneficial, unless hypoxemia is
present. Prophylactic antibiotics may be administered later in order to prevent infections.

Which medication is contraindicated in patients with sickle cell disease (SCD)?

Ibuprofen
Morphine
Meperidine
Acetaminophen
Rationale
Meperidine (pethidine [Demerol]) is not recommended. Normeperidine, a metabolite of
meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and
generalized seizures when it accumulates with repetitive dosing. Patients with SCD are
particularly at risk for normeperidine-induced seizures. Morphine, ibuprofen, and acetaminophen
are not generally contraindicated unless there is a known allergy to these medications.

Which laboratory finding indicates hemolysis?

Decreased reticulocyte count
Decreased red blood cell count
Fall in the serum bilirubin level
Presence of nucleated red blood cells
Rationale
Hemolysis is a condition that requires a rapid increase in red blood cell production.
Consequently, circulating erythrocytes may not be fully matured, and nucleated red blood cells
may appear in circulation. Increased red blood cell destruction results in increased production of
bilirubin. With increased demand for red blood cells, bone marrow is stimulated to produce an
increased number of reticulocytes as well.

Which nursing intervention is appropriate when preventing antithymocyte globulin (ATG) from
accumulating in the extravascular space of an aplastic anemia patient causing extravasation?
Administer oxygen immediately.
Closely monitor the child for fever and rashes.
Administer medication to prevent tissue damage.
Immediately administer systemic corticosteroids.
Rationale
Aplastic anemia is primarily treated with immunosuppressive agents such as antithymocyte
globulin (ATG), which makes the child susceptible to infections. Extravasation of the drug may
cause tissue damage, so medication needs to be administered. Oxygen may be required if
anaphylaxis occurs. Fever and skin rashes immediately after ATG administration are normal
reactions. Serum sickness is a delayed reaction due to ATG therapy. It is usually seen within 7 to
14 days of ATG administration. Serum sickness may be prevented by administering systemic
corticosteroids.
Which nursing action is appropriate for the child with sickle cell anemia who experiences severe
chest pain, fever, a cough, and dyspnea?
Administering 100% oxygen to relieve hypoxia
Administering pain medication to relieve symptoms
Notifying the practitioner because the child may be having a stroke
Notifying the practitioner because the child may be experiencing chest syndrome
Rationale
Severe chest pain, fever, a cough, and dyspnea are the signs and symptoms of chest syndrome.
The nurse must notify the practitioner immediately. Administration of 100% oxygen to relieve
hypoxia may be prescribed by the practitioner, but the first action is notification because these
symptoms indicate a medical emergency. Pain medications may be indicated, but evaluation is
necessary first. Severe chest pain, fever, cough, and dyspnea are not signs of a stroke.

Which nursing recommendations are appropriate when teaching the parents of a preterm infant
ways to prevent possible nutritional deficiency anemia? Select all that apply.
Provide breast milk as much as possible.
Give citrus fruit or juice with iron supplements.
Introduce fresh cow’s milk by the age of 6 months.
Administer iron supplements in two divided doses between meals.
Start iron supplementation by the age of 2 months at a rate of 1 mg/kg/day.
Limit quantities of milk and introduce solid food rich in iron, fluoride, zinc, and vitamin C.
Rationale
Breast milk is the best source of nutrition for the child and should be used for the first 12 months.
It is better to accompany iron supplements with citrus fruits and juices. They reduce the iron to
its most soluble form, which is readily absorbed in the gastrointestinal tract. Iron should be
administered in two or three divided doses between meals, when the presence of free
hydrochloric acid in the stomach is greatest. It helps in iron absorption from the stomach. Milk is
deficient in iron, fluoride, zinc, and vitamin C. These nutrients should be given with solid food.
Fresh cow’s milk should be introduced after the age of 12 months, because intolerance to milk
proteins may lead to gastrointestinal blood loss. Iron supplementation should be started at the age
of 2 months at a rate of 2 mg/kg/day for preterm babies.

Which findings are appropriate when taking the medical history of a child suffering from
anemia? Select all that apply.
Nutrition
Eating habits
Bowel habits
Family history
Family contact details
History of chronic infection
Rationale
Nutritional inquiry provides information about lactose intolerance or inadequate iron intake.
Eating habits such as consumption of dirt, starch, or paper indicates possible nutritional
deficiencies that may lead to anemia. Bowel habits like the presence of blood in the stools are
indicators of chronic blood loss that can lead to anemia. Family history of sickle cell disease
predisposes the child to anemia. Most chronic and recurrent infections may also lead to anemia.
Contact details are essential for contacting the family, but do not yield any information of
diagnostic value.

Which measure is not appropriate for the treatment of right knee pain with localized swelling for
the child with sickle cell disease?
Massaging the affected area for pain relief
Giving ibuprofen to the child for pain relief
Giving cold compression to the affected area
Informing the parent that the child needs a high dose of an opioid
Rationale
Localized swelling over a joint with arthralgia can occur in some children with sickle cell
disease. In such situations a nurse should avoid applying a cold compress to the affected area,
because it promotes vasoconstriction, leading to sickling of cells. Therefore the nurse should
apply heat, massage the affected area, and give analgesics such as ibuprofen for pain relief.
Parents should be informed that the child may require a high dose of an opioid if the pain is not
relieved and that it is completely safe.

Which nursing information is appropriate when teaching the family about caring for a child with
sickle cell anemia? Select all that apply.
Take the child to higher altitudes.
Involve the child in contact sports.
Identify early signs of dehydration.
Administer prophylactic penicillin.
Encourage the child to drink a lot of fluids.
Check the child for proper hand-washing technique.
Rationale
In a patient with sickle cell anemia, the kidneys are unable to concentrate the urine properly. This
places the child at risk for dehydration. The family needs to be able to identify the early signs of
dehydration. Dehydration may be prevented by encouraging the child to drink lots of fluids. Due
to functional asplenia, sickle cell anemia patients are more susceptible to infections than normal
children are. Prophylactic penicillin and proper hand-washing technique are recommended to
prevent infections. Taking the child to higher altitudes may worsen tissue hypoxia. Contact
sports like boxing, judo, and karate may result in direct physical damage to the spleen, causing
massive internal bleeding.

Which nursing intervention is appropriate when performing a blood transfusion?

Transfuse blood slowly for initial 20% of blood volume.
Identify donor and recipient blood types and groups.
Save donor blood for recrossmatch with patient's blood.
Send the patient's blood and urine sample to the laboratory.
Rationale
The nurse would first check the identification of the recipient and donor's blood group and type
regardless of the blood product being used. This is the first step to ensure a safe blood
transfusion without hemolytic reactions. After verifying with another nurse, the blood should be
transfused slowly for the initial 20% of blood volume. The nurse would obtain the vital signs of
the patient at frequent intervals and monitor for any reaction in the patient. In case of a reaction,
the transfusion should be stopped and donor blood saved to recrossmatch with the patient's
blood. In addition, with a reaction, the patient's blood and urine samples are sent to the
laboratory to detect the presence of hemoglobin.

Which nursing interventions are appropriate for the child undergoing a blood transfusion? Select
all that apply.
Administer the first 50 mL of blood slowly.
Administer blood through an appropriate filter.
Shake the blood container frequently while the transfusion is in progress.
Check the blood group and blood type of the child and the donor before the transfusion.
Take vital signs only before initiation, 15 minutes after initiation, and after completion of
transfusion.
Use blood within 30 minutes of its arrival from the blood bank, or store it in a regular unit
refrigerator.
Rationale
The first 50 mL of blood would be administered slowly, and the nurse should stay with the child
to check for any reaction. Blood would be administered through an appropriate filter to eliminate
particles in the blood. During the process, gently shake the blood container frequently to prevent
precipitation. Always check the donor and recipient’s blood group and blood type before the
transfusion, to prevent any complications. Once blood arrives from the blood bank, it should be
used within 30 minutes. If not used, it would be returned to the blood bank, not stored in a
regular unit refrigerator. Vital signs should be taken prior to transfusion, 15 minutes after
initiation, hourly while the transfusion is in progress, and after the transfusion is complete.

Which nursing intervention is appropriate for the child with von Willebrand disease who
suddenly develops epistaxis at school?
Apply a cold pack to the bridge of the nose.
Administer 1-deamino-8-D-arginine vasopressin.
Apply pressure to the nose with the thumb and forefinger.
Calm the child and have the child sit up and lean forward.
Rationale
In case of epistaxis, the very first measure to be taken is to make the child sit up and lean
forward to keep the airway patent. A cold pack may be applied to the bridge of the nose if
bleeding persists. When local measures are not successful in stopping the bleeding, 1-deamino-8-
D-arginine vasopressin is administered. After making the child sit up and lean forward, pressure
is applied to the nose with thumb and forefinger for at least 10 minutes. This can control the
bleeding, because most of the nosebleed originates from the anterior part of the nasal septum.

Which measure is appropriate when preventing sickling of red blood cells in a child with sickle
cell anemia that has pain in the lower limbs, pale skin and tongue, and the PaO 2 is 98%?
Administer oxygen.
Give oral analgesics.
Give intravenous fluids.
Restrict drinking of water.
Rationale
Prevention of sickling is an important measure in the management of sickle cell crisis. Hydration
of the body either through oral or intravenous fluids helps to prevent the sickling phenomenon.
The PaO 2 of the patient indicates that oxygen saturation is optimal, and therefore oxygen
administration is not required. Analgesics are given to reduce pain; however, they cannot prevent
sickling. Drinking of water should be encouraged.

How is Kostmann disease similar to familial benign neutropenia?

Both can cause monocytosis.
Both are X-linked recessive disorders.
Both show increase in plasma cells in the bone marrow.
Both can be treated with bone marrow transplantation.
Rationale
Both Kostmann disease and familial benign neutropenia show monocytosis on hematology
evaluation. Neither of the diseases is an X-linked recessive disorder. Whereas Kostmann disease
has an autosomal recessive inheritance pattern, familial benign neutropenia has a dominant
inheritance pattern. Plasma cells are increased in the marrow of patients with Kostmann disease,
but not familial benign neutropenia. Whereas bone marrow transplantation is a treatment option
for Kostmann disease, familial benign neutropenia has no therapy.

Which treatment is appropriate for the child with sickle cell anemia whose transcranial Doppler
test indicates abnormal intracranial vascular flow?
Splenectomy surgery
Multiple blood transfusions
High doses of opioids to prevent pain
Oxygen therapy to prevent hypoxia
Rationale
If the child with sickle cell anemia has an abnormal intracranial blood flow, the child is at high
risk of developing a stroke. In this case the child needs to be given chronic transfusion therapy. If
a child has recurrent sequestration of the spleen, a splenectomy must be performed to save the
child's life. Based on the knowledge that the child has abnormal intracranial vascular flow, it
cannot be determined that the child has severe pain. Oxygen therapy is given to patients with
sickle cell anemia only if they have severe hypoxia.

Which labs are appropriate when reporting abnormal blood work? Select all that apply.
Hematocrit (Hct) of 36%
Hemoglobin (Hgb) of 9.5
Platelet count of 120,000
White blood cell count of 17,500
Red blood cell count of 3.0 million
Rationale
The hemoglobin (Hgb) of 9.5 is abnormal, because average values are 11.5 to 15.5. The platelet
count of 120,000 is abnormally low, because the average value is 150,000 to 400,000. The white
blood cell count is abnormally high, because the average value is 4,500 to 13,500. The red blood
cell count is abnormally low, because the average count should be 4.5 to 5.5 million. These
values should all be reported. The hematocrit of 36% is within the normal range of 35 to 45%.
Which nursing consideration is appropriate in the care of a child with sickle cell anemia?
Referring the parents and child for genetic counseling
Helping the child and family adjust to a short-term disease
Teaching caregivers about the need for multiple blood transfusions
Teaching the parents and child how to recognize signs and symptoms of crisis
Rationale
Teaching the parents and child how to recognize signs and symptoms of crisis is most important
for the well-being and safety of the child. Genetic counseling is important, but teaching the care
of the child is a priority. Parents need specific instructions on the need to watch for changes in
the child's condition, including adequate hydration and environmental concerns. Sickle cell
anemia is a long-term, chronic illness. Multiple blood transfusions are an option for some
children with sickle cell disease. The priority for all children with this condition is properly
preparing the parents to care for them.

Which nursing action is appropriate when a child receiving a blood transfusion is experiencing
an adverse reaction?
Taking vital signs
Stopping the transfusion
Diluting the infusing blood
Notifying the health care provider
Rationale
Stopping the transfusion, obtaining new tubing, and maintaining a patent IV line with normal
saline solution are the priority nursing actions. The nurse should take vital signs and notify the
health care provider as appropriate after priority responsibilities have been fulfilled. If an adverse
reaction is occurring, it is essential to minimize the amount of blood that is infused, so stopping
the transfusion, rather than diluting the blood is appropriate.

Which finding is appropriate when teaching an adolescent female patient with sickle cell anemia
about the complications associated with her disease?
At risk for pregnancy-related disorders
Susceptible to increased insulin requirements
Given higher doses of meperidine for pain
Advised to decrease oral fluid intake
Rationale
Health education is very important for preventing complications. Sickle cell anemia is a common
problem that may lead to complications during pregnancy. Assessment of the child in sickle cell
crisis includes all areas and systems that can be affected by circulatory obstruction, including
vital signs; neurologic signs; vision; hearing; and the respiratory, gastrointestinal, renal, and
musculoskeletal systems. It is also important to identify the location and intensity of pain.
Sexually active patients would be told of the risks. Sickle cell anemia does not lead to an
increase in insulin requirements; an increase in insulin requirements is due to diabetes.
Meperidine is no longer used for pain management due to the harmful effects of its metabolite.
Hydration is important to avoid sickling of cells and to promote circulation and adequate kidney
function.
Which laboratory finding is appropriate to support the history and clinical examination for the
diagnosis of sickle cell disease?
Hematocrit level 40%
Reticulocyte count 3%
Hemoglobin level 12.2 g/dL
Platelet count 375 x 10 3/mm 3
Rationale
Children with sickle cell disease have an increased reticulocyte count. The normal range for
reticulocyte count is 0.5% to 1.5%. Hence, a reticulocyte count of 3% adds to the suspicion that
the child has sickle cell disease. Children with sickle cell disease have a decreased hematocrit
level (normal range 35% to 45%), decreased hemoglobin level (normal range 11.5 to 15.5 g/dL)
and decreased platelet count (normal range 150 to 400 x 10 3/mm 3). The hematocrit level,
hemoglobin level, and platelet count of the child are within normal ranges.

Which percentage is appropriate when describing the chances that a hemophilic male and a
female who carries the gene for hemophilia will have a normal male offspring?
0%
25%
50%
100%
Rationale
Hemophilia is an X-linked recessive disorder. The chances are equal (1 in 4) that the offspring of
an affected male and carrier female will be a normal son, an affected son, an affected daughter,
or a carrier daughter. The chance of having a normal son is 25%. Hence, the options 0%, 50%,
and 100% are incorrect.

Which nursing action is appropriate for the child that is receiving a blood transfusion and begins
having dyspnea, hypertension, and precordial pain?
Stop the transfusion.
Give antihypertensive medication.
Give epinephrine immediately.
Insert catheter and monitor hourly outputs.
Rationale
If during blood transfusion a patient has dyspnea, hypertension, precordial pain, and the nurse
suspects circulatory overload, the priority action is to stop the transfusion. Giving
antihypertensive medication is not the priority action, because the nurse needs to stop what is
causing the symptoms. Giving epinephrine is an action related to allergic reactions. Inserting a
catheter and monitoring hourly for output may be a nursing action later but is not the priority and
is most related to actions connected to hemolytic reactions.

Which explanation is appropriate for an 8-year-old child when describing what platelets are and
their purpose?
Make up the liquid portion of blood
Help keep germs from causing infection
Carry the oxygen we breathe from the lungs to all parts of the body
Help the body stop bleeding by forming a clot (scab) over the hurt area
Rationale
Platelets are involved in clotting. Keeping germs from causing infections is the function of white
blood cells. Plasma is the liquid portion of blood. Carrying oxygen is the function of the red
blood cells.

Which setting is appropriate when adjusting the flow rate to 0.5mL/minute during a blood
transfusion?
5 to 7 drops/minute
12 to 15 drops/minute
20 to 25 drops/minute
30 to 40 drops/minute
Rationale
In children, the infusion pumps of blood administration sets use regular drops rather than
microdrops. One milliliter consists of 10 or 15 regular drops. Thus, a flow rate of 0.5 ml/minute
will be 5 to 7 drops/minute. Therefore 12 to 15, 20 to 25, and 30 to 40 drops/minute are not
correct.

Which laboratory findings are common to both severe congenital neutropenia and idiopathic
autoimmune neutropenia? Select all that apply.
Anemia
Monocytosis
Absence of band stage cells in the marrow
Increase in lymphocytes in the marrow
Absence of polymorphonuclear leukocytes in the marrow
Rationale
Severe congenital neutropenia and idiopathic autoimmune neutropenia are two types of
congenital neutropenia. Hematologic evaluation shows monocytosis in both conditions.
Polymorphonuclear leukocytes are absent in the marrow in both diseases. Whereas severe
congenital neutropenia causes anemia, idiopathic autoimmune neutropenia does not. Band stage
cells are absent in the marrow in cases of severe congenital neutropenia and present in cases of
idiopathic autoimmune neutropenia. Idiopathic autoimmune neutropenia cases show an increase
in lymphocytes in the marrow. Such an increase is not seen in severe congenital neutropenia.

Which symptoms are appropriate in a child admitted for anemia related to increased blood cell
destruction? Select all that apply.
Pallor
Jaundice
Cool skin
Dark urine
Splenomegaly
Rationale
Symptoms the nurse would expect in a child admitted for anemia related to increased blood cell
destruction include jaundice, dark urine, and splenomegaly. Pallor and cool skin is most related
to anemia related to increased red blood cell loss.
Which statement is appropriate when describing the difference between deferasirox and
deferoxamine in the treatment of sickle cell anemia?
Deferasirox is a chelating agent, and deferoxamine is not.
Deferasirox prevents hemosiderosis, and deferoxamine does not.
Deferoxamine is given via an infusion pump; deferasirox is an oral agent.
Deferoxamine prevents cardiac dysfunction; deferasirox causes cardiac toxicity.
Rationale
Deferoxamine is administered intravenously or subcutaneously via an infusion pump over a
period of 8 to 10 hours for 5 to 7 days a week. Deferasirox is administered orally. Both
deferoxamine and deferasirox are chelating agents. They both prevent excessive iron deposition
in the tissues (hemosiderosis). They both prevent cardiac dysfunction.

Which method of administration is appropriate to ensure safety for an infant being treated with a
liquid iron preparation as a supplement? Select all that apply.
With a dropper toward the back of mouth
With meals for better absorption
By educating the parents that iron supplementation will cause transient diarrhea
Iron supplementation will turn stools to a black color
Avoid administering with milk products in order to increase absorption
Rationale
Iron supplementation is given to promote growth and development. However, it may stain the
teeth on exposure. Therefore, iron supplements should be administered with a dropper towards
the back of the mouth to prevent staining of the teeth. Iron supplements turn the stools to a black
or tarry green color. Intake of iron supplements with milk products causes a decrease in iron
absorption, because milk products bind with iron and prevent absorption. Iron supplements
should be taken between meals so as to increase their absorption. Iron supplements cause
transient constipation but not diarrhea.

Which characteristics are appropriate for both hereditary spherocytosis and sickle cell disease?
Both are hemoglobinopathies.
Both cause increased destruction of red blood cells.
Both are transmitted in an X-linked recessive pattern.
Both are caused by defects in phospholipids of red blood cell membranes.
Rationale
Both hereditary spherocytosis and sickle cell disease cause increased destruction of red blood
cells. They cause hemolytic anemia. Sickle cell disease is a group of hemoglobinopathies in
which normal adult hemoglobin (hemoglobin A [HgbA]) is partly or completely replaced by
abnormal sickle hemoglobin (HgbS). Hereditary spherocytosis is a disorder of the red blood cell
membrane rather than of hemoglobin. Neither hereditary spherocytosis nor sickle cell disease is
transmitted in an X-linked recessive pattern. Hereditary spherocytosis is transmitted in an
autosomal dominant pattern, although some cases may be inherited through an autosomal
recessive mode. The gene that determines the production of HgbS in sickle cell disease is on an
autosome. Neither hereditary spherocytosis nor sickle cell disease is caused by a defect in
phospholipids of red blood cell membranes.
Which nursing explanation is appropriate for the parent of a child receiving an iron preparation
whose stools are a tarry black color?
A symptom of iron deficiency anemia
An adverse effect of the iron preparation
An indicator of an iron preparation overdose
An expected change caused by the iron preparation
Rationale
An adequate dosage of iron turns the stools a tarry black color. Tarry black stools are not a sign
of iron-deficiency anemia. Tarry black stools are not an adverse effect of the iron preparation but
an expected effect. Tarry black stools are not an indicator of iron preparation overdose.

Which clinical manifestations are appropriate with the diagnosis of hemophilia? Select all that
apply.
Fever
Excessive bruising
Nausea and vomiting
Hemorrhage from any trauma
Prolonged bleeding from or in the body
Rationale
The most common clinical manifestations of hemophilia are prolonged bleeding anywhere from
or in the body, hemorrhage from any trauma, and excessive bruising. Fever, nausea, and
vomiting are not common clinical manifestations of hemophilia.

Which complication of sickle cell disease is similar to pneumonia?

Sequestration crisis
Vasoocclusive crisis
Acute chest syndrome
Cerebrovascular accident
Rationale
Acute chest syndrome is the presence of new pulmonary infiltrate that presents with symptoms
similar to those of pneumonia. Sequestration crisis, or pooling of a large amount of blood,
usually in the spleen and infrequently in the liver, is not similar to pneumonia. Vasoocclusive
crisis is a painful episode characterized by ischemia and is not similar to pneumonia.
Cerebrovascular accident is a stroke and therefore not similar to pneumonia.

Which supportive measure is appropriate for the child with hemophilia after an arm injury until
factor replacement therapy can be instituted?
Applying warm, moist compresses
Applying pressure for at least 1 minute
Elevating the area above the level of the heart
Beginning passive range-of-motion exercise unless the pain is severe
Rationale
The initial response would include elevation of the arm to minimize bleeding. Cold should be
applied to the arm. This will aid in vasoconstriction, which will in turn minimize blood loss.
Pressure is effective in small areas but would not be as effective for an extremity. Passive range-
of-motion exercise is not recommended. The child may perform active range-of-motion exercise
after the bleeding episode has resolved.

Which condition is appropriate for the child that complains of a sudden severe headache after 30
minutes of a blood transfusion?
Hepatitis
Febrile reaction to the blood transfusion
Delayed reaction to the blood transfusion
Hemolytic reaction to the blood transfusion
Rationale
A sudden, severe headache in a child receiving a blood transfusion is a symptom of a hemolytic
reaction to the blood transfusion. Hepatitis would result in a toxic reaction, high fever, severe
headache or substernal pain, hypotension, intense flushing, vomiting, or diarrhea. A febrile
reaction would result in fever. In a delayed reaction, symptoms would take longer to present.

Which clinical features are appropriate in children with sickle cell anemia? Select all that apply.
Gallstones
Hematuria
Osteomyelitis
Hepatomegaly
Chronic ulcers
Rationale
Common clinical features of sickle cell anemia found in children include gallstones, hematuria,
osteomyelitis, hepatomegaly, cerebrovascular accident, paralysis, retinopathy, blindness,
hemorrhage, avascular necrosis, splenomegaly, splenic sequestration, hyposthenuria, abdominal
pain, dactylitis, priapism, and pain. Chronic ulcers are not a common finding in children with
sickle cell anemia.

Which condition is appropriate when explaining to parents that there is a left shift on the
complete blood count for their child?
Jaundice
Bacterial infection
Sickle cell anemia
Iron-deficiency anemia
Rationale
Shift to the left is the common term used to indicate that there is an abnormal complete blood
count. This shows that there are immature neutrophils present in the peripheral blood film, which
usually occurs due to increased bone marrow function. One of the reasons for the hyperfunction
of bone marrow is bacterial infection. Jaundice is said to be present when serum bilirubin levels
increase. In sickle cell anemia, abnormal red blood cells are seen in the blood film, and in iron-
deficiency anemia, hematocrit levels decrease.

Chapter 4
Which statement explains the importance of detecting strabismus in young children?
Color vision deficit may result.
Ptosis may develop secondarily.
Amblyopia, a type of blindness, may result.
An epicanthal fold may develop in the affected eye.
Rationale
Amblyopia may develop if the eyes do not work together. The brain may ignore the visual cues
from one eye, resulting in impaired vision. Color vision depends on rods and cones in the retina,
not muscle coordination. The epicanthal folds are present at birth. Ptosis, or drooping of the
eyelid, is not related to strabismus (crossed eyes).

Which counting method is recommended when assessing the heart rate of a 1-year-old?
Radial pulse for a full minute
Brachial pulse for a full minute
Apical impulse for a full minute
Radial pulse for 30 seconds and the femoral pulse for 1 minute and comparing the two
Rationale
The recommended method for assessing a 1-year-old infant's heart rate is to use a stethoscope to
count the apical impulse for a full minute. Counting the radial pulse for a full minute is not
recommended in a 1-year-old infant; nor is counting the radial pulse for 30 seconds and the
femoral pulse for 1 minute and then comparing the two. Counting the brachial pulse for a full
minute is not the recommended method for assessing this infant's heart rate.

At which age would the nurse expect the anterior fontanel to fuse?
Third month of life
Second month of life
Between 6 and 12 months
Between 12 and 18 months
Rationale
The anterior fontanel fuses between 12 and 18 months of life. The posterior fontanel closes by
the second month of life.

Which statement is true concerning the increased use of telephone triage by nurses?
Home care is often recommended when it is not appropriate.
Telephone triage has led to an increase in the cost of health care.
Access to high-quality health care services has increased with telephone triage.
Emergency department visits are not recommended by nurses and therefore are not a component
of telephone triage.
Rationale
The judicious use of telephone triage has decreased the number of unnecessary visits, allowing
time for improved care. Health care costs have decreased because of a decreased number of
emergency departments. The triage nurse determines whether the child needs to be referred to
emergency medical services on the basis of the child's responses to screening questions. The
nurse can then initiate the call if needed. Home care is recommended only when indicated by the
answers to the screening questions.

Which are the components of an adolescent health history? Select all that apply.
Sexual history
Review of systems
Physical assessment
Growth measurements
Family medical history
Rationale
Sexual history, review of systems, and review of family medical history are all components of
the health history. Physical assessment is a component of the physical examination, as are
growth measurements.

Which method is appropriate to ensure correct measurement of the brachial artery blood
pressure?
The stethoscope bell should be placed over the radial artery pulse.
The cuff bladder length should cover 50% of the arm circumference.
Blood pressure should be measured with the cubital fossa below heart level.
The cuff bladder width should be 40% of the circumference of the upper arm.
Rationale
A properly sized cuff has a bladder width approximately 40% of the circumference of the arm
measured at a point midway between olecranon and acromion. The stethoscope bell should be
placed over the brachial artery pulse, rather than the radial artery pulse. The cuff bladder length
should cover 80% to 100%, rather than 50%, of arm circumference. Blood pressure should be
measured with the cubital fossa at heart level, rather than below heart level.

Which skin assessment provides the best determination of adequate hydration and nutrition in a
child?
Color
Turgor
Texture
Temperature
Rationale
Skin turgor or elasticity is one of the best estimates of adequate hydration and nutrition in a
child. Skin color is not the most helpful way to determine a child's level of hydration or nutrition.
Skin texture will help reveal whether the child has oily or dry skin. Skin temperature is helpful in
determining the child's level of comfort rather than hydration or nutrition status.

Which measurement results in an accurate determination of the length of a child younger than 12
months of age?
Standing height
Recumbent length measured in the prone position
Recumbent length measured in the supine position
Estimation of length to the nearest centimeter or half inch
Rationale
The crown-heel length measurement is the most accurate measurement in infants. Infants are
generally unable to stand for a height measurement. Measurement should not be estimated,
because an accurate measurement is required to determine growth. The infant should be
measured in the supine position, not the prone position.

Which assessment finding would the nurse expect when assessing a preschooler’s chest?
Respiratory movement is primarily thoracic.
Intercostal retractions occur with respirations.
Anteroposterior diameter is equal to transverse diameter.
Symmetric, bilateral chest wall movement occurs with respirations.
Rationale
The preschool-age child should have bilateral and symmetric chest movement and a coordinated
breathing pattern. At this age breathing is a coordinated function and is primarily abdominal or
diaphragmatic. Thoracic breathing occurs in older children, particularly girls. The
anteroposterior diameter is equal to the transverse diameter in infants. As the child grows, the
chest normally increases in the transverse direction; therefore the anteroposterior diameter is less
than the lateral diameter. Intercostal retractions are indicative of respiratory distress.

Which tests are used to assess visual acuity in children ages 3 to 5 years? Select all that apply.
Tumbling E
Bruckner test
Snellen letters
Snellen numbers
Ophthalmoscope
Rationale
The tumbling E and the Snellen letters and numbers are recommended tests for assessing visual
acuity in children between 3 and 5 years of age. The Bruckner test is used to test for ocular
alignment. The ophthalmoscope is used to inspect the internal structures of the eye and red
reflex.

Which test does the nurse use to assess a child’s cerebellar function?
Cover test
Finger-to-nose test
Eliciting deep tendon reflexes
Biting down hard and opening the jaw
Rationale
The finger-to-nose test is an indication of cerebellar function. The cover test is used to assess eye
alignment. Deep tendon reflexes do not indicate cerebellar function. Having the child bite down
hard and open the jaw is used to assess the strength and symmetry of the trigeminal nerve.

How would the nurse position the pinna to visualize the eardrum of a 4-year-old child?
Upward
Downward
Up and back
Down and back
Rationale
Pull the pinna up and back to visualize the eardrum in a child older than 3 years. Pulling the
pinna upward and pulling the pinna downward are not appropriate positioning techniques for
visualizing the eardrum. Pull the pinna down and back when visualizing the eardrum in an infant.

Which is the appropriate direction to pull the pinna of an infant during an otoscopic
examination?
Up and back
Up and forward
Down and back
Down and forward
Rationale
The correct procedure for examining an infant's ear is to pull the pinna down and back. Pulling
the pinna up and back is the correct position for a child 3 years or older. Pulling the pinna up and
forward will not permit sufficient visualization of the ear; neither will pulling the pinna down
and forward.

During assessment of a child with breathing problems, the nurse asks for birth history. The
parent responds, "How will pregnancy and birth affect my child's present condition?" Which is
the appropriate response by the nurse?
"Vaccines taken at birth affect a child's development."
"Prenatal influences have effects on a child's development."
"I need to check what medications were administered earlier."
"I need to know whether your pregnancy was planned or unexpected."
Rationale
Prenatal influences such as the mother's health during pregnancy, the labor and delivery, and the
infant's condition immediately after birth affect the physical and emotional development of the
child. Vaccines are given for health promotion, and negative statements about vaccines may
make the parent anxious. Medication history can be obtained without asking for the birth history
of the child. Asking whether a pregnancy was expected may embarrass the parent. The nurse
instead refers to specific facts relating to the pregnancy, such as the spacing between offspring or
pregnancy during adolescence.

Which assessment should the nurse do first when examining a content infant sitting on mother’s
lap, chewing a toy?
Examine the child head to toe.
Auscultate the heart and lungs.
Elicit reflexes in all extremities.
Examine the eyes, ears, and mouth.
Rationale
While the child is quiet, auscultation should be performed. It may disturb or upset the child to
elicit reflexes or examine the eyes, ears, and mouth first, making auscultation and the remainder
of the physical examination difficult. Although most physical examinations proceed from the
head to the feet, the nurse should perform the assessment for a child in an order that moves from
least to most disturbing from the child's perspective.

Which question is appropriate to assess a child's school performance?

"Did he go to preschool?"
"How is he doing in school?"
"Does he have problems at school?"
"Does he seem to be doing well in school?"
Rationale
"How is he doing in school?" is an open-ended question without any descriptive terms that may
limit the mother's responses. "Did he go to preschool?" is a closed-ended question that will elicit
a yes-or-no answer. "Does he have problems at school?" is a closed-ended question that implies
the child is not doing well. "How well does he seem to be doing in school?" is a closed-ended
question that will elicit a short answer and assumes that the child is doing well.

Why can it be difficult to assess a child's dietary intake?

Families usually do not understand much about nutrition.
Biochemical analysis for nutrition assessment is expensive.
Recall of children's food consumption is frequently unreliable.
No systematic assessment tool has been developed for this purpose.
Rationale
It is difficult for parents to recall exactly what their child has eaten. Concurrent food diaries are
somewhat more reliable. Systematic tools are available. Nutrients for different foods are known;
the quantity and type of food consumed are the facts that are difficult to ascertain. The family
does not need nutritional knowledge to describe what the child has eaten.

Which measure by the nurse is likely to minimize the sensation of tickling during superficial
palpation and promote relaxation?
Palpate another area simultaneously.
Ask the child not to laugh or move if it tickles.
Have the child "help" by placing a hand over the examiner’s hand.
Begin with deeper palpation and gradually progress to superficial palpation.
Rationale
Having the child "help" allows the nurse to perform the assessment while including the child in
the care. Palpating another area simultaneously would not promote relaxation and would make it
more difficult to perform the abdominal assessment. Asking a child not to laugh or move if the
examination tickles may only contribute to the child's laughter or prove frustrating for both the
child and the nurse. Deeper palpation will enhance the tickling sensation, not lessen it.

Which is the most common method of assessing dietary intake in children?

Food diary
24-hour recall
Anthropometry
Weight measurement
Rationale
In 24-hour recall, the child or parent recalls every item eaten in the past 24 hours and the
approximate amounts. The food diary is used less often because it takes more time, typically
three days of two weekdays and one weekend day. Anthropometry is the measurement of height,
weight, head circumference, proportions, skin fold thickness, and arm circumference in young
children. This reflects past nutrition and is used less commonly to assess dietary intake in
children than 24-hour recall. Weight measurement is a less commonly used method of assessing
dietary intake in children compared with 24-hour recall.

Which findings indicate a normal pupil and corneal examination? Select all that apply.
Constriction when light approaches
Round, clear, and equal appearance
Cornea appears to be milky and cloudy
Dilatation when light is suddenly flashed
Constriction if a bright object moves near the face.
Rationale
The nurse can check the child's reaction to light by quickly shining a light toward the eye and
then removing the light. The pupils should constrict when light approaches and dilate when the
light fades. Normal pupils are round, clear, and equal. The nurse can test the pupil for movement
by asking the child to look at a shiny object while the nurse moves the object toward the face.
Pupils should constrict as the object is brought near the eye. Pupils dilate when the light fades. A
milky and cloudy cornea indicates vision problems.

Which interviewing strategy should the nurse implement with a child’s parents during an in-
home visit for physical assessment?
Refrain from asking questions of the child.
Ask the parents to engage the child by turning on the television.
Ask the name of each family member and interact with that member.
Record the first names of the parents and the child on the medical record.
Rationale
While assessing the physical and mental health of the child, the nurse would interact with all the
family members present during the assessment. The nurse would first give a self-introduction.
Following this, the nurse would ask the name of each family member and address that member
with appropriate titles such as "Mr." and "Mrs." The nurse would interact with the child and ask
questions. The nurse would record the preferred name of the patient and the child's parents in the
medical record instead of the first names. This helps the nurse to build a rapport for effective
communication. The nurse suggests that the parents switch off the television, radio, and cell
phone during assessment. The child must be engaged by having toys to play with instead. It helps
the parents to concentrate and give complete information during the assessment.

Which pediatric condition is characterized by stringy, dry, and depigmented hair?

Ecchymosis
Poor nutrition
Normotension
Cerebral hypoperfusion
Rationale
The quality and texture of hair help the nurse to determine the state of nutrition. Hair that is
stringy, dry, brittle, and depigmented indicates that the child gets poor nutrition. Normotension
indicates that the child's blood pressure is below the 90th percentile and is considered normal.
Cerebral hypoperfusion is decreased blood flow to the brain. Ecchymosis is the presence of
large, diffuse areas caused by hemorrhage of blood into skin.

Which interpretation by the nurse is accurate if the anteroposterior chest diameter equals the
transverse chest diameter in an infant?
Normal
Abnormal
Normal in a child younger than 18
Reflecting a need for further evaluation
Rationale
In an infant, assessing that the anteroposterior (AP) chest diameter is equal to the transverse
diameter is considered a normal finding. Equal AP and transverse chest diameters are abnormal
in an older child. There is no need for further evaluation; as the child grows, the chest normally
increases in the transverse direction, causing the AP diameter to be less than the lateral diameter.

Which age-specific approach should a nurse use while performing a physical examination of a 6-
year-old child?
Use positive statements.
Distract using bright objects.
Perform the examination quickly.
Explain the purpose of the equipment used.
Rationale
The purpose of the equipment used for the physical examination should be explained to school-
age children during the physical examination. Positive statements must be used to gain the
cooperation of preschool children during the physical examination. During the physical
examination, bright objects can be used to distract infants and gain their cooperation. The
physical examination should be performed quickly if toddlers are uncooperative.

Which is an appropriate assessment method for the nurse to use to view the tonsils and
oropharynx of a 6-year-old child?
Ask the child to open the mouth wide and say, "Ahh!"
Examine the mouth when the child is crying to avoid use of tongue blade.
Pinch the nostrils closed until the child opens the mouth, then insert the tongue blade.
Ask the child to open the mouth wide and then placing the tongue blade in the center back area
of the tongue.
Rationale
A cooperative child can be asked to open the mouth and move the tongue around for the
examiner. No tongue blade is necessary to visualize the tonsils and oropharynx if the child
cooperates. When the child cries there is insufficient opportunity to completely visualize the
tonsils and oropharynx. It is traumatic to pinch a child's nostrils closed until the child opens the
mouth and there is no reason to use such measures, especially with cooperative children.

Which term is used to describe the reason for the child's visit to the clinic or hospital?
Present illness
Chief complaint
Current condition
Review of symptoms
Rationale
Chief complaint is the term used to describe the reason for the child's visit to the clinic or
hospital. Present illness is the narrative of the chief complaint from its earliest onset through its
progression to the present. Current condition is not a term used in the assessment. Review of
symptoms is a specific review of each body system following an order similar to that of the
physical examination.
Which nursing care guidelines would the nurse implement when communicating with
children? Select all that apply.
Be honest only when it is helpful for the child.
Avoid extended eye contact and other threatening gestures.
Hurry through the exam to help the child cope with the experience.
Communicate through transitional objects such as dolls and puppets.
Minimize or ignore fearful reactions by children to enhance coping skills.
Rationale
Transitional objects such as dolls and puppets should be used to enhance communication with
children. Avoid extended eye contact and other threatening gestures when communicating with
children. Be honest with children at all times, not just when it is perceived to be helpful for the
child. It is not helpful to hurry through the exam, which will stress the child rather than help the
child to cope with the experience. Never minimize or ignore fearful reactions by children;
instead, allow them to express their concerns and fears in a nonthreatening environment.

Which manifestation is a sign of information overload in a patient or family member?

Asking direct questions
Requesting an interpreter
Frequently looking at the clock
Directing the focus of discussion
Rationale
Frequently looking at the clock is a sign of information overload in a patient or family member.
Asking direct questions, requesting an interpreter, and directing the focus of discussion are not
signs of information overload; they are ways to enhance communication by engaging the patient
in the conversation.

Which site would a nurse use to obtain the most accurate body temperature reading in a 6-
month-old child?
Oral
Aural
Rectal
Axillary
Rationale
The rectal temperature site, which provides an accurate reading, is recommended for measuring
the temperature of younger children. The oral temperature measurement site is recommended for
older children. The aural temperature measurement site is not recommended, because it does not
provide a more accurate temperature reading. The axillary temperature measurement site is not
recommended, because it does not provide an accurate reading.

Which intervention is important when establishing therapeutic communication with adolescents?

Use nonverbal techniques.
Communicate through transition objects.
Build a foundation for a trusting relationship.
Explain procedures using short sentences and simple words.
Rationale
Building a foundation for a trusting relationship is an important part of establishing
therapeutic communications with adolescents. Many adolescents have a difficult time
understanding nonverbal cues; therefore this is not an important part of therapeutic
communication with adolescents. Communicating through transition objects, such as dolls or
toys, and using short sentences with simple words are both helpful strategies for use with
younger children.

Which signs during parent teaching support the observation of information overload? Select all
that apply.
Asking many questions
Maintaining eye contact
Fixed facial expressions
Looking at the clock frequently
Silence for a long period of time
Rationale
While interacting with patients and their guardians, the nurse would continually assess the
situation to determine that appropriate information is being provided. Giving too much
information can cause information overload. Information should be simple and concise.
Remaining silent for a long period of time indicates information overload. Frequently looking at
the clock and having an expressionless face indicate that listeners are getting impatient or bored,
which are signs of information overload. Asking many questions indicates that the parents are
concerned and actively participating in the discussion. Listeners who lose interest are unlikely to
maintain eye contact.

Which instruction does the nurse manager give to the staff when arranging the assessment room
in a new pediatric ward?
Place toys and dolls in the room.
Color the room with bright colors.
Maintain the room temperature at 59 o F.
Decorate the room with strange and novel items.
Rationale
The nurse would create an appropriate ambiance and environment in the pediatric assessment
room. This helps children to feel comfortable and interact effectively with the nurse. Children
enjoy having toys around them and to play with them. Thus, the nurse would ask the staff
members to keep toys in the pediatric ward. The room should be colored with neutral colors, not
bright colors. Bright colors can make children aggressive. A room temperature of 59 o F would
feel cold to the average person and may make patients feel uncomfortable. The nurse should
ensure that the room temperature is increased to a more comfortable level. Strange and novel
items such as frightening pictures must not be kept in the room because they may scare children.

Which condition is associated with glossy, pink-colored conjunctiva in a child?

Vitamin A deficiency
Excessive riboflavin
Adequate nutrition
Riboflavin deficiency
Rationale
The presence of clear, bright vision and a pink and glossy conjunctiva indicate adequate
nutrition. The manifestations of vitamin A deficiency are scaling of the cornea and conjunctiva.
Excessive riboflavin is characterized by paresthesia. The signs of riboflavin deficiency are
burning, itching, and photophobia.

Which nursing action promotes effective communication with an adolescent patient?

Restate the statement made by the patient.
Remain silent and just listen to the patient.
Maintain extended eye contact with the patient.
Advise the patient to take measures to maintain personal hygiene.
Rationale
The nurse would be cautious while interacting with adolescent patients as they fluctuate between
the behavioral patterns of adults and children. While interacting with an adolescent patient, the
nurse would remain silent and just listen to the patient for effective communication. It helps to
know the patient's perceptions and feelings. The nurse would not restate the statement made by
the patient, as the patient may feel criticized and become irritated. The nurse would not advise
the patient to maintain good hygiene habits, as the patient may feel judged. The nurse would not
maintain extended eye contact, as it can threaten the patient and give an impression of anger.

In which section of the health history would prematurity of birth be recorded?

Past history
Family history
Chief complaint
Review of systems
Rationale
Past history is the section of the health history where information related to the patient's previous
illnesses, injuries, or operations is recorded. Family history is where information about the child
as an individual and member of a family is recorded. Chief complaint is the main reason that a
patient is seeking professional health attention. The review of systems section is where potential
health problems are recorded.

Which questions could the nurse ask to assess the quality of a child's current dietary
intake? Select all that apply.
Does your child exercise regularly?
How often does your child brush the teeth?
What are your child's favorite snacking foods?
When did you start giving your child solid foods?
Does your child eat breakfast, lunch, and dinner daily?
Rationale
Questions about the child's favorite snacking foods and whether the child eats breakfast, lunch,
and dinner on a daily basis are important ways for the nurse to assess the quality of a child's
current dietary intake. Asking whether the child exercises regularly, how often the child brushes
the teeth, or when the child started solid foods is not a good way to assess the quality of a child's
current dietary intake.
Which statement would the nurse make to the mother of a neonate who appears tired and is not
interacting during an office visit?
"You look tired due to lack of sleep.""
"You are handling the baby very well."
"Your baby looks very cute and pretty."
Is there any problem? You seem to be sad."
Rationale
Parents are an important source of information regarding the child's health. Thus the nurse
should be able to effectively interact with the child's parents while performing the assessment of
the child. The parents of neonates generally feel tired and do not interact with the nurse, giving
monosyllabic answers. The nurse should encourage the mother by saying, "You are handling the
baby very well." Appreciating the mother for her caregiving skills would make the mother feel
happy and would stimulate effective interaction. The nurse should avoid asking, "Is there any
problem? You seem to be sad," because it diverts the conversation away from the child's health.
Appreciating the baby by saying that the baby looks very cute and pretty may be nice for the
patient to hear, but does not provide the same level of information for the nurse. The response,
"You look tired due to lack of sleep" can be used when the nurse wants to assess the mother's
health and condition.

An African American child's height and weight are in the 20th percentile on the growth chart.
Which would describe the child’s growth?
Within normal limits
Not within normal limits
Inaccurate for African American children
Not enough measurements have been plotted over time
Rationale
The growth charts are population based and include all children without regard to race or
ethnicity. A child's growth within the 20th percentile is in the normal range. Children from
different ethnic and racial groups are included, making the growth chart representative of all
groups. The growth chart is useful both for screening and for assessment over time.

Which instruction is appropriate for the nurse to give an adolescent who is untidy and has dirt
under the nails?
"I would like to talk to your mother about your habits."
"Improper hygiene will make you susceptible to infections."
"You should trim your nails or you will be prone to infections."
"A person can lead a healthier life by maintaining good hygiene."
Rationale
The child should be taught using third-person technique. Explaining that a person can lead a
healthier life by maintaining hygiene can help the child understand the importance of hygiene in
a nonthreatening manner. Statements starting with "you" indicate that the nurse is judging the
student and should thus be avoided. The response, "You should trim your nails or you will be
prone to infections," is inappropriate. The response, "Improper hygiene will make you
susceptible to infections," may make the nurse come across as a school teacher. The response, "I
would like to talk to your mother about your habits," is inappropriate. It gives the impression of
complaining and the adolescent may feel annoyed.
Which is the best intervention the nurse can implement to help involve a younger child in the
physical examination process?
Limit the number of people in the room.
Perform the examination as quickly as possible.
Allow the child to handle or hold the equipment.
Assess painful areas at the end of the examination.
Rationale
By allowing the child to handle or hold the equipment, the nurse involves the child in the
physical examination process. Examining painful areas last allays fear but will not involve the
child in the physical examination. Performing the examination as quickly as possible increases
the speed of examination but does not necessarily help the child feel more involved in the
physical examination. Limiting the number of people in the room will ensure privacy but will not
encourage the child to become involved in the physical examination.

Which intervention helps the nurse avoid stimulating the cremasteric reflex when palpating a 2-
year-old boy for the presence of testes?
Ask the boy to sit in the tailor position.
Instruct the boy to cough during the exam.
Ask the boy to sit on a cold examination table.
Have the boy exercise before beginning the assessment.
Rationale
Asking the boy to sit in the tailor or "Indian" position helps to stretch the muscle, preventing its
contraction. Instructing the boy to cough during the exam will not help to avoid stimulating the
cremasteric reflex. Exercise, excitement, and cold temperatures can stimulate the cremasteric
reflex.

Which statement is correct regarding blood pressure measurement in children?

Blood pressure is stable throughout the life span.
Korotkoff sounds can be affected by pressure on the brachial pulse.
Choosing the appropriate cuff size most accurately reflects radial arterial pressure.
Blood pressure measuring devices have no effect on the accuracy of the measurement.
Rationale
Researchers have found that the selection of a cuff with a bladder equal to approximately 40% of
the upper arm circumference most accurately reflects directly measured radial arterial pressure.
Blood pressure is not stable throughout the life span. The Korotkoff sounds can be affected by
the pressure on the antecubital fossa, but this is not the most important factor in accurately
measuring blood pressure. Blood pressure measuring devices can affect the accuracy of the
measurement.

How would a new pediatric examination room be set up?

Cool in temperature
Decorated with vibrant colors
Well-lit room with everything in view
Syringes placed in a visible region for easy access
Rationale
The room should be well lit, which will help in performing a thorough checkup. The room
should have a comfortably warm temperature. The room should be decorated with neutral colors.
Syringes should be placed out of sight of the children because they may frighten the children.

Which are atraumatic ways to encourage deep breathing in children? Select all that apply.
Have the child pretend to suck up liquid with a straw.
Ask the child to "blow out" the light on an otoscope or pocket flashlight.
Place a small tissue on the top of a pencil and ask the child to blow off the tissue.
Apply firm pressure on the stethoscope's chest piece but not enough to prevent vibrations and
transmission of sound.
Place a cotton ball in the child's palm, ask the child to blow the ball into the air, and have the
parent catch it.
Rationale
Atraumatic ways in which nurses can encourage deep breathing in children include asking the
child to "blow out" the light on an otoscope or pocket flashlight; placing a cotton ball in the
child's palm, then asking the child to blow the ball into the air and having the parent catch it; and
placing a small tissue on the top of a pencil and asking the child to blow off the tissue. Having
the child pretend to suck up liquids with a straw is not an effective way to encourage deep
breaths. Applying firm pressure on the chest piece but not enough to prevent vibrations and
transmission of sound is helpful in obtaining effective auscultation but not effective in
encouraging deep breaths.

While waiting for a translator to arrive, which action can assist the nurse in ensuring correct
translations when using children as translators?
Ask questions designed to elicit general answers.
Interrupt the parent and ask the child to translate every few sentences.
Assume that the use of children as translators is permissible in this institution.
Assess the interpreted translation in terms of verbal expressions of communication.
Rationale
Interrupting the parent and asking the child to translate every few sentences can help ensure
correct translation. Questions should be designed to elicit specific, rather than general, answers.
The nurse would always check the institutional policy to determine whether the use of children
as interpreters is permissible. Interpreted translation should be assessed in terms of nonverbal,
rather than verbal, expressions of communication.

Which anticipatory guidance measures should the nurse provide to the parents to prevent anxiety
while taking care of their infant? Select all that apply.
Inform them about support groups.
Advise them about the identified needs.
Motivate the parents to provide competent and effective care.
Suggest that they reserve adequate financial resources for optimal care.
Advise on the needs indicated only by the primary health care provider.
Rationale
The nurse would provide anticipatory guidance for the infant's parents to avoid anxiety and
stress. The nurse would consider a few factors when providing anticipatory guidance. The nurse
would give advice on the needs indicated by the infant's parents. It helps the infant's parents to
have complete information and to discuss all the questions. The nurse would inform the parents
about support groups from which they can access financial help. The nurse should consider the
infant's parents to be competent to provide effective care to the child. It helps to enhance the self-
esteem of the infant's parents. Taking care of the infant is not too expensive and thus the nurse
should not ask the parents to reserve adequate financial resources. The nurse should avoid giving
advice based only on the needs indicated by the primary health care provider. Parents may not
share some of their questions with the primary health care provider.

Which finding would the nurse identify in a child with manifestations of excessive niacin?
Scaly dermatitis
Depigmentation
Dry and rough skin
Seborrheic dermatitis
Rationale
An excess of niacin causes seborrheic dermatitis. Deficiency of vitamin A causes dry and rough
skin. Deficiency of riboflavin causes scaly dermatitis. Depigmentation is a finding of excess
vitamin A, protein, and calories.

Which factors have encouraged the increased use of telephone triage by nurses? Select all that
apply.
Increased access to high-quality health care services
Unnecessary emergency department visits have increased
Decreased patient satisfaction with medical care services
Home nursing care recommended when it is not appropriate
Empowered parents participating in their children's medical care
Rationale
Telephone triage by nurses has increased as a result of increased access to high-quality health
care services and empowered parents taking a more active role in their children's medical care.
The incidence of unnecessary emergency department visits has decreased, not increased, and
patient satisfaction with medical care services has increased rather than decreased. Guidelines for
home management are given if the triage assessment indicates that this level of care is required.
Parents are given instructions about changes in the child's condition to report.

During a physical assessment the nurse notes that the child's height and weight are below the
fifth percentile and that the child has pale skin; stringy, dull, dry, thin hair; a flat abdomen; and
generalized muscle wasting. Which nutritional deficit does the nurse suspect?
Zinc
Protein
Sodium
Vitamin A
Rationale
A deficiency in protein is evidenced by low percentiles in height and weight on the growth
charts; stringy, friable, dull, dry, thin hair; and muscle wasting. Zinc deficiency manifests as
scaly dermatitis, lesions around the nares, and a diminished sense of taste. Sodium deficiency is
manifested by weakness, pain, and cramps. Vitamin A deficiency is evidenced by skin that is
hardened or scaling, as well as dental caries.

Which action by the nurse needs correction when performing a physical examination on an
uncooperative child?
The nurse limits the number of people in the room.
The nurse uses a quiet, calm, and confident speaking voice.
The nurse performs the examination as quickly as possible.
The nurse explains the examination procedure in full detail.
Rationale
The nurse would not give prolonged explanations about the examination process. This action by
the nurse requires further teaching. Limiting the number of people in the room, using a quiet,
calm and confident voice, and performing the examination as quickly as possible will reduce the
fear in an uncooperative child during a physical examination. These are the techniques to use
when a child does not cooperate during a physical examination.

Which interpretation of skin turgor is accurate when the tissue remains suspended, or tented, for
a few seconds and then slowly falls back on the abdomen?
Proper hydration
Poor skin turgor
Normal tissue elasticity
The assessment is done incorrectly
Rationale
Tenting is the term for an indication of poor skin turgor. In normal elasticity the skin returns
immediately to its original position. If the child is properly hydrated, the skin is elastic. The
correct way to assess turgor is to grasp the skin of the abdomen between the thumb and index
finger, pull it taut, and quickly release it.

Which actions would a nurse recognize as appropriate when communicating with families
through an interpreter? Select all that apply.
Using closed-ended questions when attempting to elicit the patient's feelings
Refraining from interrupting family members and the interpreter while they are conversing
Using different interpreters with the same family as a means of validating the accuracy of
information
Being aware that cultural differences may exist with regard to views on sex, marriage, and
pregnancy
Explaining to the interpreter the reason for the interview and listing the types of questions that
will be asked
Rationale
When using an interpreter, it is important for the nurse to refrain from interrupting family
members and the interpreter while they are conversing, explain to the interpreter the reason for
the interview and what types of questions will be asked, and to be aware that cultural differences
may exist regarding views on sex, marriage, and pregnancy. Open-ended questions, not closed-
ended ones, would be used to elicit the patient's feelings. It is not appropriate for the nurse to use
different interpreters with the same family; rather, the same interpreter should be used on
subsequent visits whenever possible.
The nurse finds that a child is very shy and avoids interacting during mental and physical
assessment. Which nursing action promotes effective interaction with the child?
Smiling broadly
Using short sentences
Refraining from giving directions
Asking the parents to wait outside the room
Rationale
The nurse would follow appropriate techniques for effective communication while interacting
with the child. It helps to identify the child's condition and needs and facilitates better provision
of care. The nurse would use simple language and short sentences while interacting with
children. It helps children to understand what the nurse is asking or conveying to them. The
nurse would avoid using a broad smile because it can threaten the child. If the child is shy and is
not interacting, the nurse would initially talk to the parent until the child feels comfortable.
Asking the parents to wait outside the assessment room is not appropriate. The child may feel
threatened by the absence of the parents. The nurse would give directions and positive
suggestions to the child while interacting.

Which creative communication technique involves using the language of children to probe areas
of their thinking while bypassing conscious inhibitions or fears?
Storytelling
Facilitative response
Sentence completion
Third-person technique
Rationale
Storytelling is a creative communication technique that nurses can use with children. The
language of children is used to probe areas of their thinking while bypassing their conscious
inhibitions or fears. The simplest technique is asking a child to relate a story about an event, such
as "being in the hospital." In facilitative response, the nurse listens carefully and reflects back to
the patient the feelings and content of the statements made by the child. In sentence completion,
the nurse presents a partial statement and has the child complete it. In third-person technique, a
feeling is expressed in terms of a third person.

Which question helps the nurse to identify the severity of pain in the stomach of a school-age
child?
"Do you feel like crying when it hurts?"
"Show me where you have the most pain."
"Does the pain prevent you from sleeping?"
"Does the pain move from one side to the other?"
Rationale
The nurse can determine whether the pain is severe by finding out how the pain affects the usual
activity of the child. If the child is unable to sleep, play, eat, or interact with others, it means that
the pain is severe. Asking the child to show where it hurts or whether the pain moves from one
side to the other helps to determine the location of the pain. The nurse does not ask whether the
child feels like crying, because negative questions like this may actually make the child cry.
Which guideline would a nurse consider when developing an 8-year-old’s plan of care using an
interpreter?
Not giving the interpreter too much information so the interview evolves
Encouraging the interpreter to ask several questions at a time to make the best use of time
Explaining to the interpreter what information must be obtained from the patient and family
Discouraging the interpreter and patient from discussing topics that are irrelevant to the original
intent of the interview
Rationale
The interpreter would be given guidance regarding what information must be elicited during the
interview. One question should be asked at a time, with sufficient time left for the family to
answer. The interpreter should not have to guess what to ask and what information to obtain
during the interview. The interpreter should gain as much information from the family as they
are willing to share in response to the questions posed. Limits should not be placed on the
interview.

Which teaching technique is the nurse using when asking children to describe a picture of a child
eating a lot of chocolate and developing cavities?
Storytelling
Bibliotherapy
Mutual storytelling
Sentence completion
Rationale
With the storytelling technique, the nurse asks the child to describe a picture which helps
children learn by analyzing and thinking. In the bibliotherapy method, children are given a story
book to read. This method helps to assess the cognitive development in the children. In mutual
story telling children are encouraged to tell a story, which helps to identify children's
perceptions. In the sentence completion technique, children are given partial sentences such as
"The best thing." The children are asked to complete the sentence by filling in the blanks. This
technique helps the nurse to understand the children's feelings.

Which nursing action is appropriate when interviewing a child?

Broadly smiling
Extending eye contact
Speaking in a clear and loud voice
Talking to the parent because the child is initially shy
Rationale
The nurse would talk to the parent if the child is shy. This will make the child feel more
comfortable. The nurse would avoid having a broad smile on the face, speaking in a loud voice,
and extended eye contact; these will make the child feel threatened.

The nurse hears a loud murmur not accompanied by a thrill. How would the nurse document the
intensity of the murmur heard?
Grade V
Grade II
Grade III
Grade IV
Rationale
The nurse will grade the murmur heard as III. A grade III murmur is loud but not accompanied
by a thrill. A grade V murmur is loud enough to be heard with a stethoscope barely touching the
chest and it is accompanied by a thrill. A grade II murmur is readily heard and slightly louder
than a grade I murmur. A grade IV murmur is loud and accompanied by a thrill.

How would the nurse accurately measure the length of an 18-month-old child if a measuring
device is not available?
Stand on a scale and use a wall-mounted unit.
Stand next to a wall and mark the child's height.
Have someone assist by holding the child's head in midline while the child stands on the wall-
mounted unit.
Have the child lie on a paper-covered surface, mark the paper at the points for the top of the head
and the heels, then measure between these points.
Rationale
When a measuring device for height is not available, the best approach is to have the child lie on
a paper-covered surface while the nurse marks the top of the head and the heels and measures
between these points. Having a child of this age stand on the scale to use a wall-mounted unit is
not appropriate. Having the child stand next to the wall and marking the height is not
appropriate. Having someone assist by holding the child's head in midline while the child stands
on the wall-mounted unit, is not appropriate at this age.

Which are signs of information overload during parent teaching? Select all that apply.
Select all that apply
Eye contact
Constant fidgeting
Long periods of silence
Soft eyes and a relaxed facial expression
Attempting to change the topic of discussion
Rationale
The nurse would assess the family for the following signs of information overload: long periods
of silence, wide eyes and fixed facial expression, constant fidgeting or attempts to move away,
nervous habits (e.g. tapping, playing with hair), sudden interruptions (e.g., asking to go to the
bathroom), looking around, yawning, drooping eyes, frequently looking at a watch or clock, and
attempting to change the topic of discussion. Eye contact and soft eyes and a relaxed facial
expression are not signs of information overload.

Which statement made by the student nurse indicates effective learning for evaluating a child’s
drawing?
"Cross-hatching is a sign of happiness."
"Continuous strokes express security."
"Exclusion of a family member indicates the fear of the child."
"Larger size of individual figures represents the child’s parents."
Rationale
The type of stroke used by a child while drawing indicates the child’s feeling of security.
A continuous stroke expresses security. Cross-hatching or shading of an area expresses concern
or anxiety with a particular area. Exclusion of a family member in the drawings indicates the
feeling of not belonging or the desire to eliminate the person from the family. The size of an
individual figure in the drawing expresses the importance, power or authority in the family, not
necessarily the parents.

Which test is most commonly used to assess visual acuity in children beyond infancy?
HOTV
Tumbling E
Photoscreening
Snellen letter chart
Rationale
The Snellen letter chart is the most common test of visual acuity in children beyond infancy. The
HOTV test is a wall chart composed of the letters H, O, T, and V. The child is given a board with
a large H, O, T, and V; the examiner points to the letter on the wall chart and the child matches
the correct letter on the board by holding it up by hand. The tumbling E is used to assess visual
acuity in children who cannot read letters or numbers. The HOTV and tumbling E are excellent
tests for preschoolers, but not the most commonly used methods. Photoscreening is a technique
used to screen for amblyopia, refractive disorders, and media opacities.

Chapter 26
Which action is appropriate when understanding the peak expiratory flow rate test?
Assess the severity of asthma
Determine the cause of asthma
Identify the triggers of asthma
Confirm the diagnosis of asthma
Rationale
The peak expiratory flow rate (PEFR) test is a measure of the maximal amount of air that can be
forcefully exhaled in 1 minute. This can provide an objective measure of pulmonary function
when compared with the child's baseline. The diagnosis of asthma is made on the basis of
clinical manifestations, history, and physical examination, not pulmonary function tests such as
the PEFR. The cause of asthma is inflammation, bronchospasm, and obstruction, which are not
identified by the PEFR. Some of the triggers of asthma are identified with allergy testing, not
with the PEFR.

Which category of medication is the first-line therapy for inflammation in children with asthma?
Theophylline
Corticosteroids
Anticholinergics
Cromolyn sodium
Rationale
Corticosteroids are the first-line therapy for inflammation in children with asthma. Theophylline
is used primarily in the emergency department when the child is not responding to other
therapies. Anticholinergics relieve bronchospasm. Cromolyn sodium stabilizes mast cell
membranes.

Which primary factor is responsible for multiple clinical manifestations of cystic fibrosis?
Hyperactivity of sweat glands
Atrophic changes in mucosal wall of intestines
Hypoactivity of the autonomic nervous system
Increased viscosity of mucous gland secretions
Rationale
The primary factor responsible for clinical manifestations of cystic fibrosis is the mechanical
obstruction caused by increased viscosity of mucous gland secretions, not hyperactivity of sweat
glands, atrophic changes in the intestinal mucosal wall, or hypoactivity of the autonomic nervous
system.

Which reason is appropriate when preventing respiratory tract infections in children with
asthma?
Increase sensitivity to allergens
Lessen effectiveness of medications
Encourage exercise-induced asthma
Can trigger an episode or aggravate an asthmatic state
Rationale
A respiratory tract infection can trigger an asthmatic attack. An annual influenza vaccine is
recommended. All respiratory equipment should be kept clean. Respiratory tract infection, not
the medications, affects the asthma. Exercise-induced asthma is caused by vigorous activity, not
a respiratory tract infection. Sensitivity to allergens is independent of respiratory tract infection.

Which nursing advice is appropriate for the child being treated for infectious mononucleosis to
avoid strenuous and contact sports?
May infect others
Has splenomegaly
Needs to have a lot of rest
Is too weak for these activities
Rationale
In infectious mononucleosis, for about half the cases, the spleen is enlarged. Splenic hemorrhage
or rupture may occur due to trauma during contact sports and strenuous activities. The virus is
believed to be transmitted by direct contact with oral secretions, blood transfusion, or
transplantation. It is mildly contagious. The child should limit exposure to persons outside the
family, especially during the acute phase of illness, to prevent secondary infection. Physical
activities are not restricted in mononucleosis; rather, the child should be encouraged to maintain
limited activities to prevent deconditioning. The patient may be in considerable pain, but
activities can be undertaken as tolerated.

Which purpose is appropriate for palivizumab medication?

To prevent secondary bacterial infection
To decrease toxicity of antiviral agents
To prevent respiratory syncytial virus (RSV) infection
To make isolation of the infant with RSV unnecessary
Rationale
Palivizumab (Synagis) is a monoclonal antibody specific for respiratory syncytial virus (RSV).
The antibody is specific to RSV, not bacterial infection. Palivizumab will have no effect on the
toxicity of antiviral agents. The reason for using this drug is to prevent RSV; it will therefore not
affect the need to isolate the child if RSV infection develops.

Which complication is appropriate in the child with cystic fibrosis?

Increased insulin production
Passage of watery stools
Prolapse of the rectum
Frequent episodes of diarrhea
Rationale
Prolapse of the rectum occurs in infancy and childhood and is related to large, bulky stools;
malnutrition; and increased abdominal pressure secondary to paroxysmal cough. Clinical
manifestations of cystic fibrosis are related to increased viscosity of the mucous gland secretions.
Thick secretions block the pancreatic duct and cause severe insulin deficiency. The blockage
prevents essential pancreatic enzymes from reaching the duodenum, which causes marked
impairment in the digestion and absorption of nutrients. The disturbed function is reflected in
bulky stools that are frothy from undigested fat and foul smelling from putrefied protein.
Affected children of all ages are subject to intestinal obstruction from impacted feces. Gum-like
masses can obstruct the bowel and produce a partial or complete obstruction.

Which complication is appropriate for prolonged middle ear disorders?

Loss of hearing
Failure to thrive
Visual impairment
Tympanic membrane rupture
Rationale
Loss of hearing is the principal functional consequence of prolonged middle ear infection.
Diminished hearing has an adverse effect on the development of speech, language, and
cognition. During the active infection, loss of appetite typically occurs, and sucking or chewing
tends to aggravate the pain. This is a short-term issue; when the otitis media resolves, the child
resumes previous dietary intake. Ear infections do not have an effect on vision. Rupture of the
eardrum may occur, but the loss of hearing and subsequent effect on speech is of greater concern.

Which fluid is inappropriate when attempting to rehydrate a young child?

Water
Infalyte
Sports drink
Low-carbohydrate flavored drink
Rationale
The American Academy of Pediatrics does not recommend sports drinks or energy drinks for
rehydration. Water and low-carbohydrate flavored drinks are recommended for older children
who need to be rehydrated. Infalyte or Pedialyte is recommended for infants.

Which complication is appropriate to prevent when instructing the parents of an asthmatic child
to avoid the use of aspirin in the child?
Reye syndrome
Linear growth restriction
Less effective as an analgesic in asthma
May induce a drug reaction with other asthma drugs
Rationale
Parents should avoid giving aspirin to the child because of its association with Reye syndrome.
The administration of aspirin to a child should be specifically recommended by and under the
supervision of a health practitioner. Corticosteroids are given to children with cystic fibrosis and
may cause linear growth restriction. Other analgesic-antipyretic drugs, which do not contain
aspirin, can be used. Aspirin, though not less effective, may cause aspirin-induced asthma.
Aspirin is avoided because of its link to Reye syndrome and not because of any drug reaction.

Which endocrine disorder is commonly found in children with cystic fibrosis?

Addison disease
Diabetes mellitus
Cushing syndrome
Congenital adrenal hyperplasia
Rationale
Diabetes mellitus is more common in children with cystic fibrosis because of changes in
pancreatic architecture and diminished blood supply over time. Addison disease, Cushing
syndrome, and congenital adrenal hyperplasia are not commonly found in children with cystic
fibrosis.

Which factor is appropriate for possible multiple clinical manifestations in cystic fibrosis?
Hyperactivity of the apocrine glands
Hypoactivity of the autonomic nervous system
Atrophic changes in the mucosal wall of the intestines
Mechanical obstruction caused by increased viscosity of exocrine gland secretions
Rationale
Children with cystic fibrosis have thick exocrine gland secretions. The viscous secretions
obstruct small passages in organs such as the lungs and pancreas. Thick mucous secretions, not
atrophic changes in the intestinal mucosal walls, are the probable cause of the multiple body
system involvement. There is an identified autonomic nervous system anomaly, but it is not
hypoactivity. The apocrine, or sweat, glands are not hyperactive. The child loses a greater
amount of salt as a result of abnormal chloride movement.

Which age group is most affected by bronchitis?

Adolescents
Young adults
School-age children
Children ages 4 and under
Rationale
Bronchitis is most common during the first 4 years of life. Adolescents, young adults, and
school-age children are less susceptible to bronchitis than children ages 4 and under.

Which is the earliest postnatal manifestation of cystic fibrosis?

Steatorrhea
Azotorrhea
Meconium ileus
Pancreatic fibrosis
Rationale
Meconium ileus is the most common earliest postnatal manifestation of cystic fibrosis.
Steatorrhea is the term used to describe bulky stools from undigested fat; it is not the earliest
postnatal manifestation of cystic fibrosis. Azotorrhea, foul-smelling stools resulting from
putrefied protein, is not the earliest postnatal manifestation of cystic fibrosis. In pancreatic
fibrosis, thick secretions block the ducts; this condition is not the earliest postnatal manifestation
of cystic fibrosis.

Which reason is appropriate to avoid tonsillectomy in a 2-year-old child that has frequent sore
throats, cervical adenopathy, and exudate on the tonsils?
It is contraindicated, because it causes excessive blood loss.
It is unnecessary, because effective medicines are available.
It should be avoided in a child with exudate on the tonsils.
It should be avoided because the symptoms are mostly self-limiting.
Rationale
The tonsillectomy surgery should not be done until after 3 or 4 years of age. There is a risk of
excessive blood loss in young children. Moreover, there is a possibility of regrowth or
hypertrophy of the lymphoid tissue. Medicines are given mostly to relieve discomfort. Throat
cultures positive for streptococcal infection require antibiotic treatment. According to the
American Academy of Otolaryngology—Head and Neck Surgery (2011) list, one episode of
tonsillitis is a sore throat plus exudate on the tonsils. So, exudate on the tonsils is one of the
indications for tonsillectomy. In the case of symptoms of recurrent sore throat, cervical
adenopathy, and exudate on the tonsils, tonsillectomy may be indicated.

Which treatment is appropriate for the child with epiglottitis and severe respiratory distress?
Antibiotics
Corticosteroids
Humidified oxygen via mask
Nasotracheal intubation or tracheostomy
Rationale
The first line of treatment for the child with epiglottitis and severe respiratory distress is
nasotracheal intubation or tracheostomy. Antibiotics are given for 24 hours after the child's
airway is patent and maintained. Corticosteroids are given to reduce edema in the early treatment
phase. Humidified oxygen delivered by way of a mask is offered after intubation or
tracheostomy is performed.

Which clinical manifestations are commonly seen in both acute spasmodic laryngitis and acute
tracheitis? Select all that apply.
Dyspnea
Croupy cough
Purulent discharge
Sudden onset of symptoms
Upper respiratory tract infections
Disappearance of symptoms during the day
Rationale
Croupy cough and upper respiratory tract infections are common in both acute spasmodic
laryngitis and acute tracheitis. Dyspnea is common in acute spasmodic laryngitis. Because acute
tracheitis may be of either viral or bacterial origin with allergic component, it may be associated
with purulent discharge. This is not seen in acute spasmodic laryngitis because it is of viral
origin with an allergic component. Acute tracheitis has a moderately progressive onset of
symptoms. In acute spasmodic laryngitis, the onset of symptoms occurs suddenly at night; the
symptoms often disappear during the day.

Which clinical manifestations are appropriate for acute epiglottitis? Select all that apply.
Pain
Fever
Drooling
Tripod position
Hepatosplenomegaly
Rationale
Clinical manifestations of acute epiglottitis include fever, tripod position, drooling, pain,
irritability, restlessness, anxiousness, apprehensiveness, frightened expression, suprasternal and
substernal retractions, froglike-croaking sound, slow quiet breathing, red throat, and an
edematous epiglottis. Hepatosplenomegaly is not a common clinical manifestation of acute
epiglottitis.

Which triggers tend to precipitate or aggravate asthma in children? Select all that apply.
Select all that apply
Exercise
Breast milk
Tobacco smoke
Thyroid disease
A candle-free home
Rationale
Triggers that precipitate or aggravate asthma in children include exercise, tobacco smoke, and
thyroid disease. A candle-free home and breast milk do not trigger or aggravate asthma
symptoms in children; rather, they decrease the likelihood of an asthma exacerbation.

Which medical device is appropriate for a 4-year-old boy who cannot coordinate his breathing to
effectively use a metered-dose inhaler for asthma?
Spacer
Nebulizer
Peak expiratory flow meter
Trial of chest physiotherapy
Rationale
The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale
the medication without having to coordinate the spraying and breathing. A nebulizer is a device
for administering medications, but it cannot be used with metered-dose inhalers. Peak expiratory
flow meters are used to measure pulmonary function but are not related to medication
administration. Chest physiotherapy is unrelated to medication administration.

Which nursing advice is appropriate for the family of a child with a respiratory tract infection
that is having bouts of vomiting and refuses oral fluids?
"Give thick fruit juice to provide high calorie intake."
"Force the child to drink fluids to maintain hydration level."
"Offer the child’s favorite beverages to promote hydration."
"Give oral fluids at fixed intervals even if the child is sleeping."
Rationale
The nurse should advise the family to maintain an optimum level of hydration in the child. The
child can be offered favorite or preferred beverages. Though the beverage may not have any
nutritional content, it will help in the child’s hydration. High calorie or thick fruit juices may not
be palatable and easy to digest, because the child is vomiting. The child should not be forced to
drink fluids. It is likely that the child may develop more aversion to take food or fluids. In
addition, forcing fluids may result in vomiting. The child should not be awakened to take fluids
because this may have the same result as forcing the child to take fluids.

Which early sign of bleeding is appropriate when caring for a child after a tonsillectomy?
Bleeding gums
Continual swallowing
Bruising around the face
Bleeding from the mouth
Rationale
The most obvious early sign of bleeding in the child who has just undergone a tonsillectomy is
continual swallowing. Bleeding gums, facial bruising, and bleeding from the mouth are not the
most obvious early signs of bleeding after a tonsillectomy.

Which developmental factor increases the risk of infection in infants and young children?
The reduced exposure of infants to organisms increases their chance of infection.
The narrowed airways of young children mean that organisms move slowly down the respiratory
tract.
The relatively short and open eustachian tubes of young children give pathogens easy access to
the middle ear.
The diameter of the airways in young children is big and therefore subject to edema of the
mucous membranes.
Rationale
The relatively short and open eustachian tube in young children allows pathogens easy access to
the middle ear. The narrowed airways in young children promote quick, not slow, movement of
organisms down the respiratory tract. Increased exposure to organisms would increase the
chance of infection. The diameter of the airways in young children is not big, but small, and
therefore subject to edema of the mucous membranes.

Which statement by the parents does the nurse associate with cystic fibrosis in the child?
The infant has diarrhea.
The infant tastes "salty."
The infant has loss of appetite.
The infant has a flat abdomen.
Rationale
The parents of the infant with cystic fibrosis may report that their infant tastes "salty." A positive
sweat chloride test helps to evaluate the presence of cystic fibrosis in the child. The infant fails to
pass stools and may have large, bulky, loose, frothy, and extremely foul-smelling stools.
Meconium ileus and meconium ileus equivalent, or total or partial intestinal obstruction, can
occur at any age. The child is often constipated as a result of a combination of malabsorption
either from inadequate pancreatic enzyme dosage or a failure to take the enzymes, decreased
intestinal motility, and abnormally viscous intestinal secretions. Initially the infant has a
voracious appetite, which is now reduced. The child has a distended abdomen due to intestinal
obstruction.

Which clinical manifestation is appropriate when a pneumothorax occurs in a neonate who is

undergoing mechanical ventilation?
Wheezing
Barrel chest
Thermal instability
Nasal flaring and retractions
Rationale
Nasal flaring, retractions, and grunting are signs of respiratory distress in a neonate. Barrel chest
develops with chronic obstructive pulmonary disease, not acute pneumothorax. Wheezing has a
greater association with bronchopulmonary dysplasia or an obstruction in the airways than with
an acute pneumothorax. An acute pneumothorax would not affect the neonate's thermal stability.

Which clinical manifestations are appropriate in the child with asthma? Select all that apply.
Barrel chest
Sandpaper rash
Elevated shoulders
Edematous tongue
Increased use of accessory muscles
Rationale
The child with asthma has a barrel chest, with an increase in the anteroposterior diameter of the
chest due to infiltration and hyperexpansion of the airways. The child develops elevated
shoulders and increased use of accessory muscles. The child with scarlet fever may develop a
fine, sandpaper rash on the trunk, axillae, elbows, and groin. This child may also have edematous
and red tongue due to streptococcal infection.

How are the symptoms of acute otitis media (AOM) different from that of otitis media with
effusion (OME)?
Hearing impairment is common in AOM.
Symptoms of acute infection are common in AOM.
The tympanic member looks orange colored in AOM.
Rhinitis, cough, or diarrhea are often present with AOM.
Rationale
AOM is an inflammation of the middle ear space. AOM is accompanied by symptoms of acute
infection like fever, otalgia, and so forth. Hearing impairment can happen in both AOM and
otitis media with effusion (OME). In OME, the tympanic membrane is immobile or orange
colored. Nonspecific symptoms like rhinitis, cough, or diarrhea are often present in OME.

Which clinical features are used to determine the four asthma categories? Select all that apply.
Lung function
Associated allergies
Frequency of symptoms
Frequency and severity of exacerbations
Degree of interference with normal activities
Rationale
Peak expiratory flow rate, frequency of symptoms, frequency and severity of exacerbations, and
degree of interference with normal activities are all used to categorize asthma. Allergies are not
among the clinical features used to distinguish the categories of asthma.

Which respiratory complication is appropriate when performing discharge teaching for the
parents of an infant with an upper respiratory tract infection?
Dry cough
Waking up during naps
Decreasing irritability with fever
Refusal to drink and decreased urination
Rationale
The health professional should be notified of any refusal to take oral fluids and decreased
urination so that dehydration, which could further complicate respiratory problems, may be
prevented. Although a dry cough does not warrant contacting a health professional, persistent
cough or an exacerbated cough does. Waking up during naps does not warrant contacting the
health professional; however, restlessness and a poor sleep pattern do. Decreasing irritability
with fever does not warrant contacting a health professional; however, increasing irritability with
or without fever does.

Which therapeutic management treatments are appropriate when caring for a 2-year-old admitted
with bacterial tracheitis?
Oxygen and rehydration
Diuretics and antibiotics
Oxygen and mechanical ventilation
Oxygen therapy, antipyretics, and antibiotics
Rationale
Bacterial tracheitis is an infection of the mucosa of the upper trachea with features of both croup
and epiglottitis. This disease occurs in children younger than 3 years and requires vigorous
management with oxygen therapy, antipyretics, and antibiotics. Rehydration is not one of the top
priorities for bacterial tracheitis. Diuretics are not used as treatment. Mechanical ventilation may
be required in some patients.

The nurse understands that guidelines for administering the tuberculin skin test (TST) include:
Periodic administration for children who are at high risk
Annual administration for all children older than 2 years
Annual administration for all children older than 10 years
Annual administration for all children starting at age 1 year
Rationale
Children who are at high risk for contacting tuberculosis are tested periodically. Annual testing is
only indicated for children with human immunodeficiency virus infection and incarcerated
adolescents, no matter the age of the child.

Which nursing information is appropriate when teaching the parents of the child with
streptococcal pharyngitis?
The child is not considered infectious until antibiotic therapy is started.
The child can return to daycare after antibiotic therapy is started.
A new toothbrush must be used as soon as antibiotic therapy is started.
Orthodontic appliances used by the child must be washed thoroughly.
Rationale
Orthodontic appliances must be washed thoroughly because they may harbor organisms. The
child is considered infectious to others at the onset of symptoms and up to 24 hours after
initiation of antibiotic therapy. The child must not return to school or daycare until the child has
been taking antibiotics for a full 24-hour period. An old toothbrush must be discarded and
replaced with a new one after the child has been taking antibiotics for 24 hours.

Which condition is appropriate for the newborn who has respiratory distress, cyanosis, a
scaphoid abdomen, and a possible mediastinal shift at birth?
Asthma
Choanal atresia
Pierre Robin sequence (PRS)
Congenital diaphragmatic hernia (CDH)
Rationale
The nurse would be alert if a newborn infant has a scaphoid abdomen, moderate to severe
respiratory distress, decreased breath sounds unilaterally, and a history of polyhydramnios. The
nurse would suspect CDH and should investigate further. Asthma is mostly caused by allergens.
Infants may display supraclavicular, intercostal, suprasternal, subcostal, and sternal retractions.
However, clinical symptoms of asthma may be less obvious in infancy. Choanal atresia is a
congenital defect of the nose. A bony and/or membranous septum develops between the nose and
the pharynx. When the neonate is at rest, the neonate may become cyanotic and apneic. Once the
infant cries, the infant breathes in through the mouth and cyanosis disappears. PRS is a defect
where the tongue may be large and frequently fall over the neonate’s airway, causing respiratory
distress.

Which nursing intervention is appropriate when a 5-year-old child is brought to the emergency
department with abrupt onset of sore throat, pain with swallowing, fever, and sitting upright and
forward with acute epiglottitis suspected? Select all that apply.
Vital signs
Throat culture
Medical history
Assessment of breath sounds
Ready availability of emergency airway equipment
Rationale
Vital signs should always be taken as a part of the assessment. Medical history is important
because it aids diagnosis and allows the medical team to know the child's immunization status.
Assessment of breath sounds is important because it aids diagnosis. Suprasternal and substernal
retractions may be noted. Emergency airway equipment must be readily available in case the
airway becomes obstructed. Throat culture should never be done when epiglottis is suspected.
Manipulation of the throat could stimulate the gag reflex in an already inflamed airway and
cause laryngeal spasm that could occlude the airway.

Which nurse teaching information is appropriate for the parents of a school-age child with nasal
blockage about the use of vasoconstrictive nose drops? Select all that apply.
Administer the drops 15 to 20 minutes before feeding.
Instill two drops followed by two more drops after an hour.
Avoid using the same bottle for more than one illness.
Avoid using the same bottle for more than one child.
Instill nose drops for no more than 5 consecutive days.
Rationale
The child is able to eat and sleep comfortably when the nasal passage is clear. Therefore, nose
drops are administered 15 to 20 minutes before feeding and at bedtime. Nose drops are easily
contaminated with bacteria and viruses; therefore, they must not be used for more than one
illness or more than one child. Initially, two drops are instilled in each nostril, and, because this
shrinks only the anterior mucous membranes, two more drops are instilled 5 to 10 minutes later.
Nose drops should not be administered for more than 3 days to prevent rebound congestion.

Which recommendation is appropriate for a 20-month-old with a barking cough at night, a

temperature of 37ºC (98.6ºF), and no difficulty breathing?
Trying a cool-mist vaporizer at night and watching for signs of difficulty breathing
Bringing the child to the hospital to be admitted and to be observed for impending epiglottitis
Trying over-the-counter cough medicine and coming to the clinic tomorrow if there is no
improvement
Controlling the fever with acetaminophen (Tylenol) and calling the primary care provider if the
cough gets worse tonight
Rationale
Because the child is not experiencing difficulty breathing, the nurse should teach the parents the
signs of respiratory distress and tell them to come to the emergency department if they
develop. Cool mist is recommended to provide relief because this therapy will help open up the
child's airways. The child does not have a temperature and therefore does not require
management with acetaminophen. Cough suppressants are not indicated by the symptoms, and
the American Pediatrics Association no longer recommends over-the-counter cough medicines
for children under the age of 2 years. A barking cough is characteristic of
laryngotracheobronchitis, not epiglottitis.

Which clinical manifestations are appropriate signs of acute epiglottitis in a croup

syndrome? Select all that apply.
Drooling
Low-grade fever
Brassy cough
Stridor when supine
Toxic appearance
Rationale
Croup syndromes can affect the larynx, trachea, and bronchi. Drooling, the presence of stridor
when supine, and toxic appearances are major manifestations that are predictive of epiglottitis.
Drooling of saliva is common because of the difficulty or pain in swallowing and excessive
secretions. The child has high fever, appears sicker than clinical findings suggest, and insists on
sitting upright and leaning forward with the chin thrust out, mouth open, and tongue protruding.
Low-grade fever and brassy cough are signs of acute laryngotracheobronchitis.

Which nursing action is appropriate when performing the tuberculin skin test for a child?
Use 10 tuberculin units of purified protein derivative (PPD).
Administer medication intramuscularly in the upper arm.
Use a 14-gauge needle and a 1-mL syringe for the procedure.
Inject in such a way that a visible wheal appears on the skin.
Rationale
The nurse injects the PPD so that a visible wheal appears on the skin. A wheal 6 mm to 10 mm in
diameter should form between the layers of the skin when the solution is injected properly. If the
wheal is not formed, the procedure is repeated. A 27-gauge needle and a 1-mL syringe are used
to administer 5 tuberculin units of PPD. It is generally injected intradermally in the volar or
dorsal aspect of the forearm.

Which discharge information is appropriate for the child post tonsillectomy that is being
discharged from the hospital to the home setting?
Ice cream should be avoided.
Diluted citrus juice can be given.
A straw can be used to help drink fluids.
Fluids with a red or brown color should be avoided.
Rationale
Following tonsillectomy surgery, the child’s secretions or vomit may contain fresh or old blood.
Fluids with a red or brown color are generally avoided to distinguish any fresh or old blood from
a hemorrhage. Ice cream leaves a milk coating in the mouth and throat. It may cause the child to
clear the throat, which may irritate the operative site and cause bleeding. It can be given once
clear fluids are retained by the child. Sour food is not well tolerated at this time, so citrus fruit
juice should be avoided. A straw may hurt the operative site and it should not be used
postoperatively. p. 895

Which time is appropriate when performing bronchial postural drainage?

Before meals and at bedtime
Immediately on arising and at bedtime
Immediately before all aerosol therapy
Thirty minutes after meals and at bedtime
Rationale
The most effective time for bronchial drainage is before meals and before bedtime to prevent the
interaction of excessive amounts of mucus and food, which increases the risk of vomiting.
Bronchial drainage is more effective after other respiratory therapies such as bronchodilator or
nebulizer treatments. These treatments open the airways thereby facilitating the movement of
mucus with the positioning of bronchial drainage. Bronchial drainage should be performed three
or four times each day to be effective. When bronchial drainage is completed after meals, it may
cause the child to vomit.

Which classification is appropriate for the child that has symptoms three times a week, once a
day and receives a short-acting ß-agonist for symptom control 1 day a week?
Intermittent
Mild persistent
Severe persistent
Moderate persistent
Rationale
Symptoms three times a week once a day and use of a short-acting ß-agonist for symptom
control 1 day a week suggest mild persistent asthma. Intermittent asthma includes symptoms less
than 2 days a week and use of a short-acting ß-agonist less than 2 days a week. Moderate
persistent asthma includes daily symptoms and use of a short-acting ß-agonist daily. Severe
persistent asthma includes continual symptoms throughout the day and use of short-acting ß-
agonist several times a day.

Which clinical manifestations are appropriate to identify in a child that indicates the need for an
adenoidectomy? Select all that apply.
Chronic otitis media with effusion
Recurrent tonsil infections
Persistent foul taste or breath
Recurrent sinusitis
Sleep-disordered breathing
Rationale
Adenoidectomy is recommended for children who have chronic otitis media (OM) with effusion,
recurrent sinusitis, hypertrophied adenoids that obstruct nasal breathing, and airway obstruction
and subsequent sleep-disordered breathing. Additional indications for adenoidectomy include
current adenoiditis and sinusitis, persistent mouthbreathing, and nasal speech. Some of the
indications for a tonsillectomy include three or more tonsil infections per year and persistent foul
taste or breath caused by chronic tonsillitis.

Which nursing interventions are appropriate when preventing ventilator-associated pneumonia in

children? Select all that apply.
Evaluating the patient daily for extubation
Draining condensate from the ventilator circuit every 8 hours
Draining the ventilator circuit before repositioning the patient
Hand hygiene before and after contact with the ventilator circuit
Changing the ventilator circuits and in-line suction catheters every 24 hours to prevent infection
Rationale
Nursing interventions to prevent ventilator-associated pneumonia in children include evaluating
the patient daily for extubation, draining the ventilator circuit before repositioning the patient,
and performing hand hygiene before and after contact with the ventilator circuit. Condensate
needs to be drained from ventilator circuits more frequently than every 8 hours. Ventilator
circuits and in-line suction catheters only need to be changed when soiled, not every 24 hours.

Which nursing measures are appropriate when caring for a 10-year-old child who is suffering
from dyspnea, has difficulty in vocalizing, and has adventitious breath sounds? Select all that
apply.
Provide humidified oxygen.
Perform a thorough throat examination.
Perform suctioning of the airway as necessary.
Discourage coughing because it may irritate the throat.
Perform chest physiotherapy to facilitate secretion removal.
Rationale
The child has respiratory discomfort. Humidified oxygen helps moisten secretions and prevents
drying of the airway. If it is necessary, the nurse would perform suctioning of the airway to
remove secretions. The nurse would try to make efforts to keep the child’s airways patent. Chest
physiotherapy helps remove secretions. As the symptoms suggest, the child may have
epiglottitis. If epiglottitis is suspected, the nurse would avoid throat examination to prevent
airway compromise. The nurse would consider cough enhancement because a cough is a
protective way of clearing secretions.

Which clinical manifestations are appropriate in the young child with nasopharyngitis from
pharyngitis? Select all that apply.
Breathes through the mouth
Vomiting and diarrhea
Mild to moderate hyperemia
Vasodilation of the mucosa
Moderate sore throat
Rationale
The child with nasopharyngitis experiences discomfort related to nasal obstruction. The child has
abundant nasal mucus and breathes through the mouth. The child may be vomiting and have
diarrhea along with poor feeding and decreased fluid intake. Physical assessment also reveals
edema and vasodilation of the mucosa. The child with pharyngitis has mild to moderate
hyperemia with a moderate sore throat.

Which manifestation is appropriate to identify severe persistent asthma?

The child has a peak expiratory flow less than 60%.
The child uses short-acting β-agonist more than 2 days a week.
The child has fewer than or equal to two nighttime symptoms per month.
The child has symptoms fewer than or equal to 2 days a week.
Rationale
The child with severe persistent asthma has a peak expiratory flow (PEF) less than 60%. The
child has frequent nighttime symptoms, often more than once a week. The child uses a short-
acting β-agonist several times a week and has continual symptoms throughout the day. The child
with mild persistent asthma uses a short-acting β-agonist more than 2 days a week. The child
with intermittent asthma has nighttime symptoms or awakenings fewer than or equal to 2 nights
per month. Daytime symptoms are usually fewer than or equal to 2 days a week.

Which step is appropriate when providing nutrition for a child with nasopharyngitis who is not
taking any food or fluids?
Feed food to the child forcefully.
Wait for the symptoms to subside.
Encourage the child to take fluids only.
Provide intravenous hydration instead.
Rationale
Maintaining hydration is the most essential step. The nurse would encourage the child to take
any preferred liquid. The nurse would not force the child to eat solid foods. It may result in
nausea and vomiting and cause an aversion to feeding. As opposed to waiting until symptoms
subside, the nurse would monitor and try to maintain the hydration level in the body. Airway
compromise may occur with tonsillar swelling and the child may require intravenous hydration.
However, first oral hydration would be tried by encouraging the child to take enough fluids.

Which reason is appropriate to discourage an 11-year-old child with acute nasopharyngitis from
using a nasal drop containing phenylephrine 0.25% and ephedrine 1% for more than 3 days?
Needs to be replaced with nasal sprays
Can easily get contaminated with bacteria
Is unsafe in children under 12 years of age
Can cause rebound congestion of nasal mucosa
Rationale
The nurse discourages the use of nasal drops for more than 3 days primarily because it can cause
rebound congestion of the nasal mucosa. Older children often prefer nasal sprays to nasal drops
because they can learn to compress the plastic container at the moment of inspiration. Both
sprays and drops should be used for no more than 3 days. Bottles of nasal drops easily get
contaminated with bacteria and viruses. Hence, such bottles should be used only for one child
and only for one illness. Though nasal drops and sprays are more effective and safe in children
over 12 years of age, these can be used in children over 6 years of age.

Which nursing intervention is appropriate when promoting compliance in an adolescent with

superior lymphadenitis (extrapulmonary tuberculosis)?
Advise to use devices for cueing.
Recounsel about the importance of the medicines.
Start the patient on directly observed therapy (DOT).
Increase the frequency of followup visits and start pill counts.
Rationale
The best thing for the noncompliant adolescent would be to use the DOT program. The
compliance is important because of the rates of relapse, treatment failures, and drug resistance
among tuberculosis patients. A health care worker or other responsible individual will be present
when the medications are administered to the patient on a regular basis. This ensures better
medication compliance. The devices of cueing are helpful in medicine compliance, but because
of the severity of tuberculosis, this method is not adequately reliable for a noncompliant patient.
The adolescent may be noncompliant even if the nurse stresses the importance of taking
medicines on each followup visit. Direct observation is, therefore, a better option. Pill count is
not a reliable method because the patient can alter the medicine count.

Which clinical manifestations are appropriate in a child with asthma experiencing severe
respiratory distress requiring immediate intervention? Select all that apply.
Prefers to lie down
Sweating profusely
Severely agitated
Pink nail beds
Prolonged expiration
Rationale
The child with severe respiratory distress sweats profusely, is severely agitated, and has
prolonged expiration. The child refuses to lie down and sits upright in a hunched-over position.
If the agitated child suddenly becomes quiet, the child may have serious hypoxia and requires
immediate intervention. The child who prefers to lie down and has pink nail beds does not have
any respiratory difficulties.

Which nursing action is appropriate for the 4-year-old child who is exhibiting a "froglike"
croaking sound on inspiration, is agitated, is drooling, and insists on sitting upright?
Make the child lie down and rest quietly.
Auscultate the child's lungs and make preparations for placement in a mist tent.
Examine the child's oropharynx and report the assessment to the health care provider.
Notify the health care provider immediately and be prepared to assist with a tracheostomy or
intubation.
Rationale
Sitting upright, drooling, agitation, and a froglike cough are indicative of epiglottitis. This is a
medical emergency, and tracheostomy or intubation may be necessary. Examination of the
oropharynx may result in total obstruction and should not be done when a child manifests signs
indicating potential epiglottitis. The child assumes a tripod position to facilitate breathing.
Forcing the child to lie down will increase respiratory distress and anxiety. Interventions should
be planned once the diagnosis of epiglottitis has been made or ruled out.

Which is the first step appropriate for managing the condition of a child who comes to the
hospital with pharyngitis and a low-grade fever?
Administer oral penicillin.
Perform rapid antigen testing.
Give an antipyretic like acetaminophen.
Monitor if the symptoms are self-limiting.
Rationale
Though upper respiratory tract infections are mostly viral, streptococcal infection has more
severe clinical manifestations than a viral infection. Rapid antigen testing is done to rule out
group A beta-hemolytic streptococcus (GABHS) pharyngitis infection. If streptococcal sore
throat infection is present after a confirmatory throat culture, oral penicillin may be prescribed
and administered. If streptococcal infection is not present, then the symptoms are managed by
giving an antipyretic to relieve discomfort, and symptoms are monitored, though most viral
symptoms are self-limiting. This is done after rapid antigen testing.

Which method is appropriate when determining if a nonhospitalized child with respiratory

infection is dehydrated?
Insufficient voiding
Insufficient fluid intake
Complaint of dry mouth
Decreased level of energy
Rationale
In a child who is not acutely ill and not hospitalized, a count of the number of voids in a 24-hour
period is done to assess the level of hydration. The child may have a sore throat; therefore, the
child has a decreased urge to drink fluids. Fever increases the total body fluid turnover and
generally causes dry mouth. Often a child suffering from respiratory tract infection has a
complaint of lack of energy.

Which diagnosis is appropriate for an 1½-month-old infant who is refusing to nurse, is fussy,
crying, pulling at the ears, rolling the head from side-to-side, has nasal discharge, and a rectal
temperature of 39 oC?
Influenza
Acute pharyngitis
Acute otitis media (AOM)
Otitis media with effusion (OME)
Rationale
Most episodes of AOM occur within the first 24 months of age. Pulling the ear and rolling the
head from side to side indicate discomfort and pain in the ear. Because there is associated fever,
the child most likely has AOM. In most cases of influenza, there is dryness of the throat and
nasal mucosa and a dry cough. Fever may be accompanied by chills, flushed face, and
photophobia. Pharyngitis is characterized by an acute onset of sore throat, exudates on the
pharynx, and fever. Because there is no sore throat, pharyngitis can be ruled out. In some cases,
residual middle ear effusions remain after episodes of AOM and cause otitis media with effusion
(OME). In OME, severe pain or fever are usually absent.

Which clinical manifestation is appropriate when evaluating for a foreign body aspiration?
Cough and hoarseness
Wheezing and paroxysmal cough
Asymmetric breath sounds
Inability to speak or breathe
Rationale
Initially, a foreign body in the air passages produces choking, gagging, wheezing, or coughing.
Laryngotracheal obstruction most commonly causes dyspnea, cough, stridor, and hoarseness
because of decreased air entry. Bronchial obstruction usually produces paroxysmal cough,
wheezing, asymmetric breath sounds, decreased airway entry, and dyspnea. When an object is
lodged in the larynx, the child is unable to speak or breathe. Cyanosis may occur if the
obstruction becomes worse.
Which findings are appropriate to assess before discharge for the child with chronic respiratory
illness that is being transferred to home care? Select all that apply.
The child's medical, nursing, and other therapeutic needs
Family members' coping skills and adjustment needs
Family's access to respite care and emergency plans
Access to emergency care and transport plans
The child's ability to perform self-care
Rationale
Predischarge assessment includes identifying the child's medical, nursing, and other therapeutic
needs so that there is no confusion in case of an emergency. The nurse also assesses the family's
coping skills to ensure that the family adjusts to the stressors effectively. The nurse ensures that
the family has access to respite care and emergency plans so that there is no risk to the child. The
nurse also ensures that the family has access to emergency care and the transportation for it so
that any emergency can be promptly addressed. Assessing the child's ability to perform self-care
is not a requirement of predischarge assessment, because it can be taught while providing care.

Which symptoms distinguish seasonal allergies from common colds? Select all that apply.
Allergies are mostly accompanied by fever.
Severe bouts of sneezing are common in colds.
Nasal itching is common in case of allergic rhinitis.
Atopic dermatitis or asthma often accompanies allergic rhinitis.
Children may display dark circles beneath their eyes with allergies.
Rationale
In case of allergic rhinitis, nasal itching is common. The nurse can often distinguish
allergies from other types of rhinitis by the presence of nasal itching. Often a child develops
atopic dermatitis or asthma with seasonal allergies. There is an obstruction of normal outflow
from regional lymphatics and veins, because of which a child displays "allergic shiners" or dark
circles beneath the eyes in case of allergies. Allergies are rarely accompanied by fever. Severe
bouts of sneezing are common in allergies and not in colds.

Which method is appropriate to prevent pulmonary infection in a child who was recently
diagnosed with pulmonary involvement in cystic fibrosis?
Nasal lavaging
Aerobic exercises
Airway clearance therapy (ACT)
Therapy with antimicrobial agent
Rationale
In cystic fibrosis, the mucous secretions remain obstructed and are retained in the lungs. Bacteria
thrive in this stagnant mucus. ACT is helpful in removing secretions and prevents infection as a
whole. Nasal lavaging is performed to irrigate the nasal cavity. It is limited to the nasal cavity
only; it may not prevent pulmonary infections. Aerobic exercises help maintain healthy lung
tissue and effective ventilation and can be used as an adjunct to ACT. Antimicrobial agents are
used after an infection occurs and help to control disease progression. These agents do not
prevent pulmonary infections.
Which reason is appropriate for the nurse to discourage the parent from giving the child an over-
the-counter cough suppressant to a 5-year-old child who has fever, nasal discharge, and
productive cough?
Cough suppressant can cause addiction.
Cough is a protective way of clearing secretions.
Cough suppressants have doubtful effectiveness.
Cough medicines can lead to confusion, nausea, and sedation.
Rationale
Cough is a natural mechanism to clear secretions from the body. The nurse would do chest
physiotherapy and encourage the patient to cough in order to remove secretions. Cough
suppressants may be prescribed for a dry, hacking cough rather than a productive cough. An
over-the-counter cough suppressant used when not needed may result in addiction and may be
detrimental to the health. The effectiveness of cough suppressants is doubtful. Some cough
suppressants contain up to 22% alcohol and can cause confusion, hyperexcitability, dizziness,
nausea, and sedation. Hence, health care providers carefully evaluate the benefits and risks of
recommending these medicines to children under 6 years of age.

Which nursing intervention is appropriate for the 5-year-old child brought to the emergency
department with signs of apprehension, whose voice is thick and muffled, and also has drooling,
agitation, and no spontaneous cough?
Keep the child in close monitoring for 24 hours.
Perform a throat examination using a tongue depressor.
Swab both tonsils and posterior pharynx for throat culture.
Have the child seen by a primary care provider immediately.
Rationale
The symptoms suggest that the child may have epiglottitis. In this case, the child needs
immediate medical intervention, because the symptoms are rapidly progressive. The child should
be taken to the primary care provider who can start effective antibiotic therapy. The child should
not simply be kept under observation. An immediate care plan for airway protection should be in
place. Treatment with humidified oxygen, fluids, and antibiotics are given as needed. Because
the child is suspected to have epiglottitis, a throat examination and a swab should not be
performed due to the chance of airway compromise.

Which nursing intervention is appropriate for a child after tonsillectomy?

Watching for continuous swallowing
Applying warm compresses to the throat
Encouraging gargling to reduce discomfort
Positioning the child on the back for sleeping
Rationale
Frequent swallowing is the most obvious early sign of bleeding from the surgical site in a child
who has undergone tonsillectomy. Gargling would be avoided after a tonsillectomy because of
the potential for trauma to the suture line. The child would be positioned on the side or abdomen
to facilitate drainage after a tonsillectomy. Ice collars and cold liquids are encouraged for the
child who has had a tonsillectomy. Cold therapy soothes and anesthetizes the area, easing the
pain. Heat or warmth would increase the risk of bleeding.
Which nursing intervention is appropriate to promote maximum ventilatory function in a child
with acute asthma exacerbation?
Administer humidified oxygen.
Encourage oral fluids frequently.
Initiate a peripheral intravenous line.
Allow the child to assume a position of comfort.
Rationale
The child would be allowed to assume the tripod position or other comfortable position. This
allows maximum ventilatory function. This is the first step to follow in case of an asthma
exacerbation. Humidified oxygen is administered to enhance oxygenation of the tissues.
Frequent, small amounts of oral fluids are given to maintain hydration. Initiating a peripheral
intravenous line is a more aggressive intervention that may need to be done when initial rescue
medication fails.

Which method is appropriate for the nurse to continue care management for a child that is
hospitalized with cystic fibrosis and often refuses nursing interventions?
Develop a daily schedule of events with the child.
Perform the interventions even if the child resists.
Avoid waking up the child to perform any activities.
Use a little force to make the child allow the activities.
Rationale
There are several therapies, tests, and medication regimens to be followed in a child with cystic
fibrosis. If the child resists some interventions, the nurse would develop a daily schedule of
events with the child. This gives the child some control. The exclusion of any intervention from
the daily regimen can worsen the child’s condition; therefore, the nurse should develop a way to
do all the required activities even though the child resists. However, as much as possible, the
interventions should be performed with the child’s consent and cooperation. The activities would
be performed on time. Therefore, if it is required, the child would be awakened to perform the
activity. The nurse would have a frank discussion with the child. The child would not be forced
to cooperate, or the child may become more resistant to any interventions being performed.

Which nursing interventions are appropriate for the child after a tonsillectomy and
adenoidectomy procedure? Select all that apply.
Encourage coughing to remove any secretions.
Administer pain medication at regular intervals.
Notify the surgeon if there is frequent swallowing.
Restrict movement by making the child lie down in the bed.
Notify the surgeon if there is dark brown blood in the emesis.
Rationale
The throat remains sore after surgery. Most children experience moderate pain and need pain
medication at regular intervals for the first 24 to 48 hours. If there is fresh bleeding, it will trickle
down the throat. This will lead to the child swallowing excessively. This is the most obvious sign
of bleeding and the nurse should immediately notify the surgeon. The child would not cough to
clear the throat, because it may aggravate the operative site. The child’s movement would be
restricted, but if the child prefers, the child may be allowed to sit up in the bed. There will be
dark brown old blood in the emesis, in the nose, and between the teeth. This is common and
there is no need of urgent intervention.

Which nursing responsibilities are appropriate for the child in a home care setting? Select all
that apply.
Monitoring the child's medical condition
Identifying and accessing resources
Managing chronic sorrow
Recognizing stressors
Teaching technology to the family
Rationale
The nurse would monitor the child's medical condition by assessing the child's condition and
identifying the potential risks to the child. The nurse identifies and accesses resources such as
emergency services and transportation services to meet the child's needs. The nurse also manages
chronic sorrow by identifying proper coping strategies. The nurse recognizes stressors so that
they do not hinder care. The family members may not be literate enough to use technology such
as the Internet or email for communication; therefore, the nurse provides care instructions in a
way that is understood by the family.

Which statement is appropriate for infectious mononucleosis?

Human herpesvirus type 2 is the principal cause.
Herpes-like Epstein-Barr virus is the principal cause.
Diagnosis is established by a complete blood count, which reveals a characteristic leukopenia.
Diagnosis is established by clinical manifestations because diagnostic tests cannot confirm the
diagnosis.
Rationale
Herpes-like Epstein-Barr virus accounts for most cases of mononucleosis. A complete blood
count in an adolescent with mononucleosis would indicate a lymphocytic leukocytosis with
atypical lymph, not leukopenia. The monospot test is a highly specific test for mononucleosis.

Why should ibuprofen be given with food or milk?

To reduce dehydration
To suppress the bad taste
To prevent stomach upset
To enhance the drug action
Rationale
Ibuprofen irritates the stomach, so it is always advisable to take the drug with food or milk. Food
or milk reduces dehydration. This action is irrespective of the action of the drug. However, when
food or milk is given along with the drug, it protects the stomach from irritation. Food or milk is
not given to suppress the bad taste, but to avoid side effects of the drug. The drug action does not
depend on taking food or milk.

Chapter 10
Which age is fetal hemoglobin (HgbF) still present in the body?
5 months
6 months
7 months
8 months
Rationale
Fetal hemoglobin (HgbF) persists in the body until 5 months of age. Fetal hemoglobin (HgbF)
usually disappears after that, and should not be seen in children of ages 6, 7, or 8 months.

Which task, according to Erikson, belongs to infancy?

Trust
Industry
Initiative
Separation
Rationale
The task of infancy is the development of trust. If the infant is not successful with this task, then
mistrust develops. Industry versus inferiority is the developmental task of school-age children.
Initiative versus guilt is the developmental task of preschoolers. Separation occurs during
the sensorimotor stage, as described by Piaget.

Which characteristic best describes the fine motor skills of a 5-month-old infant?
Crude pincer grasp
Able to grasp an object voluntarily
Able to build a tower of two cubes
Ability to transfer objects from one hand to another
Rationale
The ability to grasp objects voluntarily is an appropriate fine motor skill for a 5-month-old
infant. Transferring objects from one hand to another is an appropriate fine motor skill for a 7-
month-old infant. A crude pincer grasp is an appropriate fine motor skill for an 8- to 9-month-old
infant. The ability to build a tower of two cubes is an appropriate fine motor skill for a 15-
month-old infant.

Which condition is the infant at risk for if given honey before the recommended age of 12
months?
Tetanus
Diarrhea
Botulism
Allergic reaction
Rationale
The use of honey should be discouraged for the initial 12 months to reduce the risk of botulism.
Use of honey does not increase the risk of tetanus. Honey does not cause diarrhea. It is a
honeybee sting, not honey that causes allergic manifestations.

Which number of deciduous teeth would be present in a child one and a half years of age?
Ten
Twelve
Fourteen
Sixteen
Rationale
A nurse should know the formula used to assess the number of deciduous teeth of children under
2 years of age. It is as follows: number of deciduous teeth of children under 2 years of age = age
of the child in months – 6. Therefore, in this case, the number of teeth = 18 – 6 = 12.

Which age is appropriate for children to begin smiling at their own mirror image?
2 months
3 months
4 months
5 months
Rationale
Children smile at their mirror image by the time they are 5 months old. At 2 months, children
start demonstrating a social smile in response to various stimuli. At 3 months of age, children
show interest in their surroundings, can recognize familiar faces and objects, and show
awareness of strange situations. At 4 months of age, children start enjoying social interactions
with people.

Which phase of cognitive development are infants in, according to Piaget?

Sensorimotor
Separation anxiety
Trust versus mistrust
Separation-individuation
Rationale
According to Piaget, infants are in the sensorimotor phase of cognitive development. Separation
anxiety is when infants begin to have some awareness of themselves and their mothers as
separate beings. Trust versus mistrust is the stage of development Erikson used to describe
infants. Separation-individuation is a phase of attachment during which the infant separates from
the parent.

Which anticipatory guidance statement is appropriate for the nurse to tell a mother about the
introduction of solid foods?
Rice cereal may be mixed with whole milk.
Rice is a good first food because it is easily digested and low in allergenic potential.
The introduction of solid foods at this age is for growth and development rather than taste.
Cream of farina is a good first food because it is easily digested and low in allergenic potential.
Rationale
Rice is recommended as a first solid food because it is easily digested and low in allergenic
potential. Rice cereal cannot be mixed with whole milk until the infant is 1 year old. The
introduction of solid foods at this age is for taste and chewing rather than growth and
development. Cream of farina is not recommended because it is not a good source of iron.

Which age is appropriate for primitive reflexes to begin to fade?

2 months
3 months
4 months
5 months
Rationale
At 3 months of age the primitive reflexes begin to fade. Two months of age is too young, and 4
and 5 months of age are both too old.

Which factor is appropriate to assess the degree of fit between an infant's temperament and the
interactions between the child and parents?
Similar temperaments
Different temperaments
Infant behavior that is consistently outside the parent's expectations
Harmony between the parent's expectations and the child's actual temperament
Rationale
The most appropriate factor in determining the degree of fit between an infant's temperament and
the interactions between the child and parent is harmony between the parent's expectations and
the child's actual temperament. Similar temperaments, differing temperaments, and infant
behavior consistently outside the parent's expectations are not the most important factors in
determining the degree of fit between the child and parents.

Which condition is an appropriate concern for an infant who does not pull to a standing position
by 11 to 12 months of age?
Head lag
Binocularity
Palmar grasp
Developmental dysplasia of the hip
Rationale
An infant who does not pull to a standing position by 11 to 12 months of age should be evaluated
for developmental dysplasia of the hip. Head lag disappears around 4 to 6 months of age and is
not evidenced by an inability to pull to a standing position. Binocularity is the fixation of two
ocular images into one cerebral picture and is not evidenced by an infant who cannot pull to a
standing position at 11 to 12 months of age. Palmar grasp is the ability to grasp with the whole
hand; it usually appears between 2 and 3 months of age and persists until 8 to 10 months of age.

Which recommendation would the nurse provide to a mother of a 7-month-old infant asking for
fruit juice?
Pear juice
Apple juice
Grape juice
Orange juice
Rationale
The nurse recommends providing orange juice to the infant, because it contains vitamin C. Pear,
apple, and grape juices should be avoided, because they contain high amounts of fructose and
sorbitol, which may cause diarrhea, bloating, and abdominal pain in some children.

Which Piaget stage of development do children typically solve problems through trial and error?
Sensorimotor
Preoperational
Formal operational
Concrete operational
Rationale
During the sensorimotor stage, infants and young toddlers develop a sense of cause and effect.
Relational problem-solving is characteristic of the preoperational stage. Adolescents, in the
formal operations stage, can test hypotheses. Children in the concrete operations stage solve
problems in a tangible, systematic fashion.

Which recommendation is appropriate for relief of teething pain?

Rub the gums with aspirin to relieve inflammation.
Apply hydrogen peroxide to the gums to relieve irritation.
Give the child a cold teething ring to relieve inflammation.
Have the child chew on a warm teething ring to encourage tooth eruption.
Rationale
Cold reduces inflammation and should be used for relief of teething irritation. Aspirin and
aspirin products should never be used in infants and children for inflammation or pain relief.
Hydrogen peroxide will not be effective and may irritate the gums more. Cold, not warmth,
reduces inflammation; therefore heat is not effective for teething pain.

Which gross motor skill is appropriate when assessing a 7-month-old infant?

Fixating on small objects
Sitting erect momentarily
Banging cubes on the table
Balancing the head while in the sitting position
Rationale
At 7 months of age an infant should be able to sit erect momentarily. Fixating on small objects is
a sensory skill that a 7-month-old infant should be able to perform. Banging cubes on a table is a
fine motor skill that a 7-month-old infant should be able to perform. An infant at the age of 4
months, not 7 months, should be able to balance the head while in a sitting position.

Which finding would the nurse expect while assessing a 4-month-old during a well-child visit?
Saying a name
Reaching for a toy
Picking up finger food
Sitting up with support
Rationale
A 4-month-old infant will be able to sit with support because the convex cervical curve appears
at approximately this age. Uttering recognizable words such as the name of a family member
occurs at about 7 months of age. An infant will reach for a toy at the age of 8 months. Picking
up finger foods occurs when an infant is approximately 10 months of age.

Which factors are important when selecting a daycare facility for a child? Select all that apply.
Discipline policy
Safety measures
Adequate parking
Caregiver-to-student ratio
Infection-control procedures
Rationale
When guiding an infant's parents about the selection of a daycare facility for their child, it is
most important for the nurse to instruct the parents to evaluate the facility's discipline policy,
infection-control procedures, safety precautions, and caregiver-to-student ratio. Adequate
parking is not an important area to be evaluated in the choice of a daycare facility.

Which statement is appropriate to describe growth during the first year of life?
Growth is especially rapid during the first 6 months of the first year of life.
Growth is especially rapid during the final 3 months of the first year of life.
Height slows during the first 6 months of life and increases during second 6 months.
Head circumference increases by approximately 2 cm during the first 6 months of life.
Rationale
Growth is especially rapid during the first 6 months of the first year of life. Growth slows a little
during the second 6 months of the first year of life. Height slows during the initial 6 months of
life and increases during second 6 months. Head circumference increases by about 1.5 cm, rather
than 2 cm, during the first 6 months of life.

Which recommendation is appropriate when the mother of an 8-month-old wants to discontinue

breastfeeding?
Offer whole cow's milk.
Feed organic skim milk.
Avoid commercial canned formulas.
Feed commercial iron-fortified formula.
Rationale
For children younger than 1 year of age, the American Academy of Pediatrics recommends the
use of breast milk. If breastfeeding has been discontinued, an iron-fortified commercial formula
should be used. Whole milk is not recommended until 12 months of age. Skim milk is not
recommended at 8 months because the infant needs some fat for neurologic development.

Which recommendation is appropriate as a substitution for breast milk in a 4-month-old infant?

Skim milk
Cow’s milk
Low-fat milk
Iron-fortified formula
Rationale
The primary health care provider recommends substituting iron-fortified formula for breast milk
because iron-fortified formula supplies all the nutrients needed for the infant for the first 6
months, similar to human milk. Skim milk, cow’s milk, and low-fat milk are not recommended
because there is a high risk of contamination and a lack of needed nutrients. Infants also find
these difficult to digest. Moreover, essential fatty acids are found in inadequate concentrations in
skim and low-fat milk whereas proteins and electrolytes are found in high concentrations.

Which advice is appropriate for parents that warmed expressed breast milk in a microwave for 3
minutes causing oral burns in the infant?
Provide only chilled milk to the baby to avoid oral burns.
Warm the expressed milk in the microwave only for 1 minute.
Never use a microwave for warming the expressed breast milk.
Warm the expressed milk in the microwave for 30 seconds only.
Rationale
Parents should be advised that they should never thaw or rewarm expressed milk in a microwave
because it can cause uneven warming of milk and result in oral burns. They should be advised to
thaw the frozen milk by placing it in lukewarm water.

Which information would the nurse provide to the mother of a 3-month-old breastfed infant
when asked about giving the baby water?
Fluids in addition to breast milk are not needed.
Clear juice is better than water for promoting adequate fluid intake.
Water should be given if the infant seems to nurse longer than usual.
Water once or twice a day will make up for losses due to environmental temperature.
Rationale
The infant will nurse according to the infant’s needs. Additional fluids are not necessary for a
breastfed baby. Water is not a replacement for breast milk. Infants should take as much breast
milk as they desire; this will meet their fluid requirements. Breast milk will provide the fluids
that the infant requires. Supplementation with water is not necessary. Clear juices should not be
given to a 3-month-old infant. Breast milk will provide the necessary calories and fluid intake
that an infant requires, even in the warm summer months.

Which behavior is appropriate for an 8-month-old infant who clings to the parent, cries, and
turns away from a new babysitter?
Attachment
Stranger fear
Separation anxiety
Abnormal behavior
Rationale
Stranger fear occurs between the ages of 6 and 8 months. Attachment is marked by smiles and
interaction and demonstration of trusting behaviors with the mother or main caregiver.
Separation anxiety manifests as protest when the mother or main caregiver leaves the room.
Clinging to the parent, crying, and turning away from a new babysitter is not abnormal behavior
at this stage of development.

Which developmental finding warrants further investigation by the nurse while assessing a 5-
month-old infant?
Ability to roll from back to side
Ability to turn over from the abdomen to the back
No head lag when the infant is pulled to sitting position
Inability to hold the head erect and steady when sitting
Rationale
At age 5 months an infant should be able to hold the head erect and steady when sitting. A 4-
month-old infant should be able to roll from back to side. The infant is expected to exhibit
no head lag when pulled to a sitting position. The 5-month-old infant should be able to turn from
abdomen to back.
Which statement is appropriate when interviewing the parent of a 10-month-old infant that cries
and screams whenever left with the grandparents?
The infant is most likely spoiled.
The grandparents are not responsive to the infant.
Stranger anxiety is common for an infant of this age.
Separation anxiety should have disappeared between 4 and 8 months of age.
Rationale
The infant is experiencing stranger anxiety, which is expected for an infant of this age. Stranger
anxiety usually develops by between 6 and 8 months of age and begins to disappear at about 1
year of age. The behavior the infant is exhibiting is normal and not indicative of a spoiled child.
Separation anxiety is common between 6 and 8 months of age. There are no data to support the
conclusion that the grandparents are not responsive to the infant.

Which age does the infant elicit a parachute reflex, move an object from one hand to another,
and sit leaning forward on the hands for support?
4 months
7 months
11 months
10 months
Rationale
At 7 months, infants will exhibit a parachute reflex as a protective mechanism against falls. They
are able to transfer an object from one hand to another and can sit alone leaning forward on their
hands for support. Infants are able to sit with support at 4 months, walk by holding onto furniture
at 11 months, and turn from a prone position to a sitting position at 10 months.

Which action made by the mother of a 5-month-old indicates effective learning from the nurse
about play?
Showing the child large pictures in books
Providing bright-colored toys for play
Making funny faces to encourage imitation
Teaching the child to build a two-block tower
Rationale
The mother should give bright-colored toys to a 5-month-old infant to play with. The toys should
be small enough for the infant to grasp, but large enough that they do not pose a choking hazard.
Infants at an age of 9 to 12 months are encouraged to play by looking at large pictures in books.
Infants at the age of 6 to 9 months are encouraged to imitate actions and sounds. Infants are
encouraged to build a two-block tower at the age of 9 to 12 months; at this point they have more
developed sensorimotor skills.

Which age is appropriate for a child with 10 deciduous teeth?

10 months
14 months
16 months
18 months
Rationale
As per the quick guide during the initial 2 years of the child: the age of the child in months minus
6 = number of teeth. Hence the age of the child in months = number of deciduous teeth + 6.
Applying this formula for this child, the age of the child in months is 10 + 6 = 16.

Which age is appropriate for infants who lift their head and chest, recognize their feeding bottle,
can look at their own hand while sitting back or lying down, and are able to accommodate to
nearby objects?
10 days
1 month
4 months
12 months
Rationale
The infant in the figure is 4 months old. Infants are able to lift their head and chest to 90 degrees
and bear weight on their forearms at the age of 4 months. Infants show head lag when they are 10
days old. Infants are able to momentarily lift their head at the age of 1 month. They are able to
lift their head, chest, and upper abdomen and can bear their weight on their hands at the age of
12 months.

Which finding would the nurse recognize in a 6-month-old infant who smiles, coos, and exhibits
a strong head lag?
The child is probably cognitively impaired.
This is normal development for a 6-month-old infant.
A developmental and neurologic evaluation is needed.
The parent needs to work with the infant to stop the head lag.
Rationale
The head lag should be almost gone by 4 months of age. This child requires further evaluation to
determine whether a developmental or neuromuscular deficit needs to be addressed. The infant
should have begun smiling and cooing by 4 to 5 months of age. A 6-month-old infant should be
imitating sounds, babbling, and vocalizing to toys and a mirror image. No determination of
cognitive impairment can be made on the basis of three assessment findings alone; additional
assessment is required.

Which method is appropriate when warming frozen milk before feeding the baby?
Use of a microwave to warm it.
Use of a lukewarm water bath to warm it.
Leaving the milk in the refrigerator overnight and heating it on stove next day.
Placing the milk in the refrigerator overnight and then warming it in the microwave.
Rationale
Frozen milk should be warmed slowly and evenly by placing the container in a lukewarm water
bath. Microwaving milk is an oral burn risk and reduces the nutritional value of milk.

Which behavior is appropriate for a mother that works 8 hours and expresses milk once during
this time whose 2-month-old baby is not gaining weight?
Taking the baby along to the office
Expressing milk at least every 3 to 4 hours
Quitting her job and breastfeeding the baby
Switching to infant formula milk for the baby
Rationale
Employed mothers should be encouraged to continue breastfeeding with appropriate guidance.
At home they can breastfeed on demand. But when at the workplace, they should express their
milk at least every 3 to 4 hours to maintain adequate milk supply. This milk can be stored in the
refrigerator at the workplace and can be fed to the baby. The mother should not be advised to
quit the job or take the baby along to the office, because these actions are not feasible. The
mother should not be advised to switch to infant formula milk, because breast milk is the best
source of nutrition.

Which response is appropriate for the nurse to give to the parent of a 12-month-old infant who
pushes the teaspoon out of the parent’s hand and makes a mess during feedings?
"Let's think of ways to make the mess more tolerable for you."
"It's important not to give in to this kind of temper tantrum at this age."
"Maybe you need to try a different type of spoon, one designed for children."
"It's important to let the child make a mess. Just don't worry about it so much."
Rationale
At 12 months, children should be self-feeding. Because they primarily eat finger foods,
providing some concrete strategies for the parent to minimize the mess would be helpful. The
child is developmentally ready for self-feeding, and this behavior reflects the child’s desire to be
autonomous. Infants between the ages of 9 and 12 months begin to self-feed; therefore this
behavior should be encouraged. Most infants begin self-feeding with finger foods, so the use of a
spoon is generally not required, limiting the "mess." Telling the parent that it is important to
allow the child to make a mess and to not worry about it minimizes the parent's concerns about
the mess created by self-feeding, blocks communication, and misses a teaching-learning
opportunity.

Which age is appropriate for children to smile at their own mirror image, differentiate strangers
from family, and exhibit mood swings?
5 months
7 months
8 months
9 months
Rationale
Infants are able to differentiate strangers from family members and smile at their mirror image at
the age of 5 months. They are very playful and exhibit mood swings. Infants hold their arms out
to be picked up and have definite likes and dislikes at the age of 7 months. Infants exhibit fear
for strangers and dislike changing dresses and diapers at the age of 8 months. Infants show an
increased interest in pleasing their parents and do not like their hands being washed at the age of
9 months.

Which response made by the parent requires further teaching about the safety measures to be
taken at home?
"I keep the oven door closed."
"I do not cover the mattress with a plastic cover."
"I store plastic bags in a place my child can’t reach."
"I provide attractive small toys for my child to play with."
Rationale
Parents should not provide small toys to infants. Infants identify objects by putting them in their
mouth, which may lead to suffocation. All appliance doors should be kept closed to avoid
electric shocks. Mattresses and pillows should not be covered with plastic, because this can lead
to suffocation. Plastic bags, which cause suffocation, should be kept out of the reach of infants.

Which information is appropriate when teaching a mother about nutritional support measures in
the initial 6 months of life? Select all that apply.
Breastfed infants do not require supplemental water in the initial 4 months.
Iron-containing foods should not be started during the initial 6 months of life.
Daily supplementation of vitamin D (400 IU) should be given during the initial few days.
Fluoride supplementation should be given from 4 months of age in exclusively breastfed infants.
Daily supplementation of vitamin D and vitamin B 12 is recommended if maternal intake is
inadequate.
Rationale
Breastfed or bottle-fed infants do not require water during the initial 4 months, because excessive
water intake results in water intoxication and hyponatremia. The American Academy of
Pediatrics recommends daily supplementation of vitamin D (400 IU) during the initial few days
to prevent rickets and vitamin D deficiency. Daily supplementation of vitamin D and vitamin
B 12 is recommended if maternal intake is inadequate. Iron-containing foods should be started
after 4 months of age exclusively in breastfed infants. Fluoride supplementation to prevent dental
fluorosis is not required for exclusively breastfed infants until 6 months of age.

Which nursing documentation is appropriate for a 5-month-old being pulled to a sitting position
without head lag?
Note a cognitive delay.
Document a normal finding.
Consider a developmental delay.
This finding is evidence of child abuse.
Rationale
Absence of head lag at 5 months of age is a normal finding. It is not indicative of developmental
or cognitive delay, nor is it evidence of child abuse.

Which nursing action is appropriate for the infant who has developed constipation while using
iron supplements?
Switch to whole milk.
Use low-iron formula.
Use high-iron–containing formula.
Do not switch to low-iron–containing formula or whole milk.
Rationale
Transient constipation is a side effect of iron supplementation. An infant requires adequate iron
stores for optimal growth and development. Parents should be educated that they should not
switch to low-iron containing formula or whole milk when constipation occurs. Low-iron–
containing formula and whole milk are poor sources of iron and can lead to iron deficiency
anemia. Iron should always be given in quantities advised by the primary health care provider.
Which nursing instruction about injury prevention would be appropriate during a 4-month-old
well baby checkup?
"Keep the doors of appliances closed at all times."
"Never shake baby powder directly on the baby, because it can be aspirated into the lungs."
"Don't let the baby chew paint from window ledges, because lead may be absorbed or ingested."
"When the baby learns to roll over, you'll need to continue to supervise especially if the baby is
at risk of falling from a surface."
Rationale
Rolling over from the abdomen to the back occurs between 4 and 7 months of age. This
statement is the appropriate anticipatory guidance for this age related to the prevention of
injuries. "Never shake baby powder directly on the baby, because it can be aspirated into the
lungs," is appropriate guidance for a first month well baby checkup related to injury prevention.
Information on lead, and lead sources, should be included at the 9-month visit, when the child is
beginning to crawl and can move to a standing position. Guidance regarding appliances and
keeping doors of appliances closed should also be included at this time.

Which supplement recommendation is appropriate to prevent the breastfed infant from

developing rickets?
Fluoride
Folic acid
Vitamin A
Vitamin D
Rationale
A supplement of 400 international units of vitamin D should be provided to prevent rickets in
breastfed infants. Fluoride, folic acid, and vitamin A are all present in human milk. Therefore, it
is not necessary to provide these nutrients in the form of supplements.

Which statement made by one of the parents indicates effective learning after receiving
education about offering fruit juices to their infant?
"I would offer juice in a bottle."
"I would offer a juice mix from the supermarket."
"I would cover and refrigerate the juice in a juice container."
"I would warm the refrigerated fruit juice before offering it to my infant."
Rationale
The container of fruit juice should be kept covered and refrigerated to avoid vitamin loss.
Offering juice in a bottle can lead to dental caries. Only 100% fresh juice should be offered to
the infant. Never warm the fruit juice because heat destroys vitamin C, an essential nutrient.

Which response from the nurse is appropriate when determining a 3-month-old baby is being fed
with low-fat milk? Select all that apply.
"It is high in sodium."
"It contains inadequate proteins."
"It has a high propensity to cause colic."
"It has a propensity to cause diarrhea."
"It contains inadequate essential fatty acids."
Rationale
Children who are 3 months old are at the stage of growth and development where they should
not be fed low-fat milk, because fats are necessary for optimal growth and development. Low-fat
milk is rich in electrolytes such as sodium. The essential fatty acids in low-fat milk are
inadequate. Low-fat milk has a high protein concentration. Low-fat milk does not cause colic.
Low-fat milk does not cause diarrhea.

Which nursing advice would be given to the parents of an 8-month-old infant on supplemental
iron who is being fed broiled chicken liver, mashed hard-boiled egg yolk, and iron-fortified
cereal? Select all that apply.
Add whole cow's milk.
Stop the iron supplement.
Continue mashed egg yolk.
Continue broiled chicken liver.
Add canned fruits and vegetables.
Rationale
When an infant is taking iron-fortified cereals, the parents would be advised to stop iron
supplements. By the age of 8 to 10 months, organ meats such as liver can be included in the
baby's diet. Mashed egg yolk from a hard-boiled egg should be introduced at the age of 12
months to prevent allergies. Liver is rich in iron, vitamin A, and vitamin B complex. Canned
fruits and vegetables should not be included in the baby's diet, because they may contain high
lead content, salt, sugar, or preservatives. Whole cow's milk can be introduced only after 12
months of age.

Which nursing response is appropriate when educating parents of a 9-month-old infant about the
baby’s thumb sucking?
A pacifier should be substituted for the thumb.
Thumb sucking should be discouraged by age 12 months.
There is no need to restrain nonnutritive sucking during infancy.
Thumb sucking should be discouraged when permanent teeth begin to erupt.
Rationale
Thumb sucking reaches its peak at 18 to 20 months of age; it should be discouraged if it persists
beyond 4 to 6 years of age. Evidence is inconclusive as to whether a pacifier or a thumb better
satisfies sucking needs and what the impact of either is on tooth eruption. Thumb sucking
reaches its peak at 18 to 20 months of age; it should be discouraged if it persists beyond 4 to 6
years of age. Nonnutritive sucking reaches its peak at about 18 to 20 months of age. Most
toddlers give up nonnutritive sucking on their own.

Which nursing guidance is appropriate when educating a mother about the proper utilization of
expressed breast milk? Select all that apply.
Expressed breast milk can be warmed in a microwave.
Breast milk should always be expressed using a breast pump.
The milk should be stored in an airtight glass or plastic container.
Expressed breast milk can be stored up to 6 months by freezing it.
Milk can safely be stored up to 5 days in the refrigerator at 4° C (39° F).
Rationale
Nursing mothers who go back to work may store expressed breast milk to continue feeding the
baby. However, certain precautions are necessary for storage of the expressed breast milk to
prevent its spoilage. Expressed breast milk may be stored up to 6 months by freezing it.
Expressed breast milk may also be stored in a refrigerator at 4° C (39° F) for up to 5 days.
Expressed breast milk should be stored either in an airtight glass bottle or a plastic container.
Breast milk may either be expressed by hand or through the use of a pump. Warming breast milk
in the microwave results in the loss of anti-infective substances and vitamin C. It even affects the
fat content of milk, and hence it is not desirable.

Which characteristic behavior would the nurse expect the 6-month-old infant to exhibit at a well-
child check?
Tries to build a tower of two blocks
Walks with one hand held by parent
Plays peek-a-boo with the nurse or parent
Transfers objects from one hand to another
Rationale
A 6-month-old infant plays games such as peek-a-boo when the infant’s head is hidden in a
towel. Infants will be able to walk with one hand held by the age of 1 year. Infants will be able to
build a tower using two blocks when they are 1 year old. Infants will be able to transfer an object
from one hand to another by the age of 7 months.

Which information would the nurse provide to the mother of a 3-month-old breastfed infant
when asked about giving the baby water?
Fluids in addition to breast milk are not needed.
Clear juice is better than water for promoting adequate fluid intake.
Water should be given if the infant seems to nurse longer than usual.
Water once or twice a day will make up for losses due to environmental temperature.
Rationale
The infant will nurse according to the infant’s needs. Additional fluids are not necessary for a
breastfed baby. Water is not a replacement for breast milk. Infants should take as much breast
milk as they desire; this will meet their fluid requirements. Breast milk will provide the fluids
that the infant requires. Supplementation with water is not necessary. Clear juices should not be
given to a 3-month-old infant. Breast milk will provide the necessary calories and fluid intake
that an infant requires, even in the warm summer months.

Which information would the nurse include while educating mothers about the usage of walkers
to prevent injuries in young children?
Mobile walkers increase coordination and prevent falls in children.
All walkers should be avoided to prevent accidental injuries in children.
Stationary walkers are preferable to mobile walkers to prevent accidents.
Children using mobile walkers tend to walk sooner than those using stationary ones.
Rationale
Stationary walkers are preferred over mobile walkers, because they prevent accidental injuries
due to slipping. It is not necessarily true that all walkers need to be avoided to prevent injuries,
though parents should never use walkers near stairs. Mobile walkers do not increase coordination
and there is no substantial evidence supporting the use of walkers in early establishment of
independent walking in children.

Which indication of system maturation would the nurse find in a 2-month-old infant during a
well check visit?
Diminished iron stores
Decreased red blood cells
A rise in systolic pressure
Lowered level of immunoglobulin G
Rationale
Systolic pressure rises during the first 2 months in infants. The systolic pressure attains values
closer to those at birth after 3 months. Iron stores, which are derived maternally, diminish by the
age of 6 months. Physiologic anemia is a commonly occurring condition among infants age 3 to
6 months. This is due to the presence of hemoglobin F, which shortens the survival of red blood
cells. The level of immunoglobulin G lowers until 6 months of age in infants.

Which reply is appropriate to provide when educating a mother about her 9-month-old child’s
thumb sucking habit?
"The use of a pacifier should be encouraged during the night."
"Thumb sucking should be discouraged at the age of 12 months."
"Thumb sucking should be discouraged when the teeth begin to erupt."
"Restraining thumb sucking doesn’t need to be discouraged during infancy."
Rationale
The nurse replies that there is no need to restrain thumb sucking at this age. Sucking gives the
infants pleasure that cannot be obtained through breastfeeding or bottle-feeding. Nonnutritive
sucking such as thumb sucking reaches its peak at 18 to 20 months. It is not necessary to
discourage thumb sucking at the age of 12 months. Thumb sucking leads to malocclusion at the
age of 4 years or when the permanent teeth start to erupt.

Which nursing action is appropriate when assessing a child that cannot pull to a standing position
by 12 months of age?
Evaluate for dysplasia of the hip joint in the child.
Assess for dysplasia of the knee joint in the child.
Reassure the parents to wait for a few more months.
Instruct the parents that a child pulls to a standing position at 18 months.
Rationale
Usually a child is able to pull up to a standing position by 12 months of age. However, if the
child does not attain this milestone, the child needs to be evaluated for dysplasia of the hip joint.
The child needs evaluation for dysplasia of the hip joint, but not the knee joint. Reassurance that
they may wait for another few months is not appropriate, because it is an expected milestone of
development. If not attained at this stage, this means there is a developmental delay. A child can
normally pull up to a standing position by 9 months of age and should be doing so before 18
months of age.

Which factors place an infant at risk for reactive attachment disorder? Select all that apply.
Parental alcoholism
Parental mental illness
Being a victim of neglect
Having been in foster care
Being the child of a single parent
Rationale
Risk factors for reactive attachment disorder (RAD) in infants include parental
alcoholism/substance abuse, abuse or neglect of the infant, and parental mental illness. Foster
care, institutionalization, and abandonment by a parent are also risk factors for RAD. Being the
child of a single parent does not increase an infant's risk for RAD.

Which intervention would the nurse recommend to the parents to encourage self-soothing
behaviors for sleep in a 4-month-old?
Letting the infant cry until falling asleep
Having the infant sleep with the parents to feel safe
Putting the infant to bed when the infant is drowsy but still awake
Rocking the infant until asleep and then softly placing the infant in a bassinet
Rationale
When parents put the infant to bed drowsy but still awake, the child learns how to fall asleep
independently. This encourages self-soothing behaviors. Letting the infant cry until falling asleep
is not recommended; it is also difficult for many parents to implement. Co-bedding can be
unsafe. Rocking the infant until the infant is asleep and then placing the infant in a bassinet
teaches the infant to rely on others to fall asleep instead of encouraging self-soothing behaviors.

Which response made by the parent indicates a need for further teaching about prevention of
infant burns at home?
"I have installed smoke detectors in my home."
"I do not leave my child in a parked car."
"I heat baby food in a microwave."
"I check bath water temperature before using."
Rationale
The infant’s food should not be heated using a microwave oven, because it can lead to uneven
heating of the food and may cause burns. The parents should always check the temperature of
fluids before feeding. Not leaving the child in a parked car, installing a smoke detector, and
checking the bath water temperature before using it will prevent the infant from experiencing
burns.

Which response made by the parent indicates a need for further education about sanitary and
safety practices for preventing infection in the home?
"I rinse reusable diapers in the toilet."
"I use disposable paper diapers for my child."
"I change the diapers as soon as they are soiled."
"I wash my hands after changing my child’s diaper."
Rationale
Reusable diapers should not be rinsed in the toilet, although fecal contents can be flushed down.
This will spread infection. Using disposable paper diapers will help in preventing infection,
because the diapers are discarded after one use. Diapers should be changed when they are soiled
to prevent infection. Children and parents should wash their hands after changing diapers; this
will help in controlling infection.

Which condition is the infant at risk of developing when the mother of a 4-month-old infant has
stopped giving iron-fortified formula and is giving honey for constipation? Select all that apply.
Select all that apply
Rickets
Obesity
Hyponatremia
Infant botulism
Iron deficiency anemia
Rationale
Honey should be avoided in infants’ first 12 months, because of the risk of botulism. Iron-
fortified formula, which is considered the best substitute for breast milk, contains all the nutrients
that an infant needs in the first 6 months of life. Stopping iron-fortified formula may lead to iron
deficiency anemia. Lack of vitamin D in the infant’s diet will lead to the development of rickets.
Infants who consume an excess of infant cereal, fruits, and vegetables are at a risk of developing
obesity. Excess intake of water in infants may lead to hyponatremia and water intoxication.

Which nursing action is appropriate when the mother of an 18-month-old expresses concern over
her child still sucking the thumb?
Report the mother's concerns to the proper authorities.
Ignore the mother's concerns because the behavior is normal.
Investigate the mother's feelings regarding her child's behavior.
Assure that the mother that her child's thumb sucking is not her fault.
Rationale
It is important for the nurse to examine the mother's feelings and then base advice on the
information that the parent has provided. It is not necessary to report the mother's concerns to the
proper authorities, and ignoring the mother's concerns is inappropriate. It is not helpful to assure
the mother that her child's thumb sucking is not her fault.

Which weight in kilograms would the nurse expect a healthy 6-month-old infant to weigh with a
birth weight of 7 pounds 8 ounces?
5.5
7.0
8.8
9.8
Rationale
Birth weight doubles around 5 to 6 months of age. At 6 months of age, a child who weighed 3.5
kg at birth should weight approximately 7.0 kg. Five and one-half kilograms is too little weight
gain for this infant. A weight of either 8.8 kg or 9.8 kg at the 6-month visit would represent a
tripling of the birth weight, which is too much. Remember: 1 kg = 2.2 pounds.

Which behavior made by the parent indicates effective learning about relieving infant teething
pain?
Providing a hard candy
Using teething powders
Rubbing the infant’s gums with aspirin
Providing a frozen teething ring to the infant
Rationale
The primary health care provider suggests a frozen teething ring, which will help in relieving
inflammation. The parent should not provide hard candy, which may lead to choking and
aspiration. The health care provider does not recommend the use of teething powders, which may
lead to irritation of the tissues and aspiration. Rubbing gums with aspirin is not recommended,
because it may lead to aspirin aspiration.

Which response made by the mother indicates effective learning about proper breast milk
storage?
"I reheat the frozen milk on the stove."
"I reheat the refrigerated expressed milk in a microwave oven."
"I thaw the milk by placing it in a container with lukewarm water."
"I store the pumped milk in a refrigerator at 10 o Celsius or 40 o Fahrenheit."
Rationale
Refrigerated breast milk should be warmed by placing it in a container with lukewarm water at a
temperature of 40.5° Celsius. The milk should not be heated on the stove, because this could lead
to oral burns in the infant, but instead should be rewarmed. Pumped breast milk should not be
reheated using a microwave, because this, too, may lead to oral burns. The availability of anti-
infective properties and vitamin C in the expressed milk may cause the separation of the milk
layers when heated using a microwave. The pumped breast milk should be stored in a
refrigerator at a temperature of 4° Celsius or 40° Fahrenheit.

Which response is appropriate to the parent when finding an 8-month-old infant cannot walk a
few steps, is unable to sit without support, and transfers a toy between hands?
"I'm sorry to hear about the developmental delay in your baby."
"At this age infants are expected to play comfortably with strangers."
"I understand your concern; we will make your child walk very soon."
"At this age the babies do not walk; they may walk after a few months more."
Rationale
The parent should be informed that an 8-month-old baby cannot walk without support. However,
the baby may be able to sit without support and transfer objects between the hands. Because the
baby's development is normal, the nurse should not say that the baby has developmental delay.
The nurse should not give false assurance, because it is impossible to make the 8-month-old baby
walk without support. Children between the ages of 6 to 8 months do not like to play with
strangers.

Which finding in a 4-month-old baby would raise concern regarding the development of social
skills and cognition?
Not recognizing the parent
Fussing during bottle-feeding
Not recognizing the feeding bottle
Not being able to roll from back to side
Rationale
If a baby is on bottle-feeding, the baby should be able to recognize the feeding bottle by the third
month. By the fourth month, the baby anticipates feeding on seeing the bottle. Infants usually
recognize their parents by the sixth month of life. It is normal for a baby to be fussy in the fourth
month of life. They demand attention by being fussy. They should be able to roll from back to
side by the fourth month of life, but this is a gross motor skill and is not an indicator of social
skill or cognition development.

Which finding is correct about object permanence in infants?

They enjoy playing with their mother.
They smile when their mother talks to them.
They cry when their mother hands them to a babysitter.
They turn and look for their mother when she walks out of sight.
Rationale
Object permanence is a critical component of the parent-child attachment. It can be seen in the
development of separation anxiety at the age of 6 to 8 months. Infants will turn and look for their
mother when she walks out of sight, indicating that even though an object is not visible, the
infant still believes that it exists. Infants will enjoy playing with their mother beginning at
approximately 8 weeks, when they will be attached to the mother and respond to others. Infants
of 1 month smile to demonstrate pleasure. Infants will cry when they are handed to a babysitter,
because they differentiate the babysitter from family members.

Which response is appropriate regarding the weight and height gain in a 1-year-old infant whose
birth weight was 3250 g, 7-month weight was 5000 g, and current weight is 9800 g and height
was 67 cm at 6 months of age? Select all that apply.
Birth to 6 months is poor in the infant.
Birth to 6 months is good in the infant.
Weight gain from 6 months to 12 months is poor in the infant.
Weight gain from 6 months to 12 months is good in the infant.
By 1 year of age, the infant's height is expected to be 134 cm.
Rationale
Weight gain is rapid in the first 6 months of life, and an infant's weight should be doubled by 6
months of age. It slows down a bit in the second 6 months of life. By 12 months of age, the
infant's birth weight should be tripled. Birth weight of this infant was 3250 g. It should have been
about 6500 g by 6 months, but the infant weighed only 5000 g. Therefore weight gain was poor
during this time. The weight of this infant by 1 year of age is expected to be about 9750 g, but
the infant weighed 9800 g. Therefore the weight gain was good in the second 6 months. Average
height of babies by 6 months is about 64 cm. Birth height of the baby increases almost 50% by 1
year, and average height of babies by this age is expected to be about 74 cm.

Which condition in a 6-month-old infant is consistent with drooling, sucking more often on the
fingers, and biting on objects?
Illness
Cavities
Teething
Viral disease
Rationale
A 6-month-old infant who is drooling, sucking on the fingers, and biting on toys and other
objects is most likely teething. Illness generally manifests as vomiting, fever, or diarrhea.
Cavities are not typically a problem for 6-month-old infants. Viral disease is generally marked
by signs and symptoms of vomiting, rash, fever, or diarrhea.

Which age would the nurse expect the infant to be able to say "mama" and "dada" with meaning?
4 months
6 months
10 months
14 months
Rationale
At 10 months of age, infants say sounds with meaning. Consonants, such as n, k, g, p, and b, are
made by an infant at 4 months of age. Babbling resembling one-syllable sounds occurs at 6
months of age. Age 14 months is late for the development of sounds with meaning. Between the
age of 1 and 2 years, the number of words should increase from approximately 4 words to 300
words.

Which age is an infant expected to say three to five words besides "dada" and "mama"?
8 months
9 months
10 months
12 months
Rationale
At 12 months of age an infant is expected to say three to five words besides "dada" and "mama."
At 8 months of age the infant is expected to combine syllables in words such as "dada" but not
ascribe meaning to them. At 9 months the infant can comprehend simple commands. At 10
months the infant can say "dada" and "mama" with meaning and may say one more word.

Chapter 12
Which characteristic is appropriate for motor skills of a 24-month-old child?
Walks alone but falls easily.
Activities begin to produce purposeful results.
Able to grasp small objects but cannot release them at will.
Motor skills are fully developed but occur in isolation from the environment.
Rationale
Gross and fine motor mastery occurs with other activities that have a purpose, such as walking to
a particular location or putting down one toy and picking up a new one. By 2 years of age
children are able to walk up and down stairs without falling. Grasping small objects without
being able to release them is characteristic of infancy. Interaction with the environment is
essential for mastery of both fine and gross motor skills at this age and beyond.

Which behavior as described by Erikson is exhibited in a toddler who always replies "No!" to the
mother’s requests?
Ritualism
Negativism
Development of ego
Development of superego
Rationale
In negativism, a common stage of toddler development, the child makes attempts at self-
expression with consistently negative responses to requests. Ritualism is the need to maintain
sameness and reliability, which provides the infant with a sense of comfort. In the development
of the superego, the toddler incorporates the morals of society and begins the process of
acculturation. Development of the ego is thought to be the beginning of reason or common sense.

Which condition describes when toddlers manifest a decreased nutritional need and a diminished
appetite?
Grazing
Ritualism
Regression
Physiologic anorexia
Rationale
In physiologic anorexia, a normal phenomenon that occurs around 18 months of age, the toddler
manifests a decreased nutritional need and diminished appetite. In ritualism, the toddler prefers
to have the same food, cup, or spoon with every meal. In regression, the toddler retreats from the
current level of function to a past level of behavior. Grazing is an eating pattern of nibbling or
snacking throughout the day.

Which behavior is appropriate when describing a toddler’s eating habits of eating a lot then
nothing at all the next day or refusing a favorite food?
Displaying symptoms of anorexia.
Becomes unpredictable after 20 months of age.
Influenced by the psychologic components of food.
The parent is consistent about mealtimes with the child.
Rationale
At the age of 18 months, toddlers show signs of decreased appetite by being fussy eaters or
having strong taste preferences. These children are influenced by the psychologic components of
the food instead of taste. They are more interested in the pleasure of eating or the social aspect of
mealtime. This phenomenon is called physiologic anorexia. The child may become unpredictable
during mealtimes, but it does not mean that the child generally becomes unpredictable after 20
months. A consistent mealtime contributes to the child's need for ritualism and helps to reduce
undesirable behavior at mealtimes.

Which type of play is characteristic of the toddler?

Tactile
Solitary
Parallel
Cooperative
Rationale
Children progress from solitary play during infancy to parallel play during toddlerhood. Tactile
play is exploratory play in which the toddler uses water toys, finger paints, or other manipulative
objects to play. Cooperative play is not characteristic of a toddler's play.

Which activity documented by the nurse describes the fine motor skills of a 2-year-old child?
Throws a ball
Imitates drawing a circle
Imitates drawing a vertical line
Drops a pellet into a narrow-necked bottle
Rationale
Fine motor skills can be demonstrated in a 2-year-old child by the child’s adeptness to imitate
drawing a vertical line or a circular stroke. When a child is 18 months old, the child is able to
throw a ball without losing balance. By the end of the toddler period, that is, by the end of 3
years of life, the child is able to copy a circle and mimic a cross. A 15-month-old child is able to
drop a pellet into a narrow-necked bottle.

Which gross motor skill is developmentally appropriate for a toddler who is 18 months of age?
Creeps up stairs
Jumps in place with both feet
Stands on one foot momentarily
Kicks ball forward without overbalancing
Rationale
At 18 months of age toddlers are expected to jump in place with both feet. Creeping up stairs
occurs at 15 months of age. At 30 months of age most toddlers can stand on one foot
momentarily. Kicking the ball forward without overbalancing is developmentally appropriate at
24 months of age.

Which characteristics of physical development are appropriate in a 30-month-old child? Select

all that apply.
Genital fondling is noted.
The anterior fontanel is open.
The birth weight has doubled.
Primary dentition is complete.
Sphincter control has been achieved.
Rationale
Sphincter control in preparation for bowel and bladder control is usually achieved by 30 months
of age. Primary dentition is usually completed by 30 months of age. The anterior fontanel closes
between 12 and 18 months of age. Birth weight should have doubled at 5 to 6 months of age and
quadrupled by 2½ years of age. Genital fondling is not a characteristic of physical development
in this age group; this is part of the development of gender identity.

Which condition is the 3-year-old at risk for when offered food as a reward?
Rickets
Obesity
Early childhood caries
Iron-deficiency anemia
Rationale
If food is offered as reward, the child may overeat for nonnutritive reasons. Therefore the child
may be at risk for obesity. Caries is caused by frequent nocturnal breastfeeding or coating
pacifiers in honey. Iron-deficiency anemia may occur if the child does not consume enough iron-
enriched foods. Rickets is caused by vitamin D deficiency.

Which response by the nurse is appropriate when asked whether meat and hot dogs can be
included in the toddler’s diet?
"Slice the meat into small pieces before serving."
"No, the child will not be able to chew it properly."
"Yes, but you must serve it in the child's favorite dish."
"Serve it less often, because it may cause early childhood caries."
Rationale
The nurse advises the parent to slice the meat and hot dogs into small pieces to prevent choking.
A child may be more accepting of foods served in a favorite dish, but it must be cut into smaller
pieces. Meat and hot dogs do not cause early childhood caries; it is caused by frequent nocturnal
breastfeeding or coating pacifiers in honey. A child is able to chew small pieces of food after 1
year of age.

Which statement by the parent suggests the need for additional information about injury
prevention in early childhood?
"We keep all of the medicines out of reach."
"We have a fence around the swimming pool."
"We've put gates at the top and bottom of our stairs."
"Our 2-year-old takes a bath with a sibling while we cook dinner."
Rationale
Allowing a 2-year-old toddler to take a bath unsupervised suggests that the parent needs
additional information about injury prevention in early childhood. Keeping all medicines out of
reach or locked, placing gates at the top and bottom of the stairs, and having a fence around the
swimming pool are all ways to prevent injury and therefore do not warrant additional teaching
about injury prevention.

Which intervention will foster the achievement of autonomy in toddlers?

Helping toddlers complete tasks
Helping toddlers learn the difference between right and wrong
Providing opportunities for toddlers to play with other children
Encouraging toddlers to do things for themselves when capable
Rationale
Toddlers have an increased ability to control their bodies, themselves, and the environment.
Autonomy develops when children complete tasks of which they are capable. To successfully
achieve autonomy, the toddler needs to have a sense of accomplishment. This does not occur if
parents complete tasks. The concept of right and wrong is too advanced for toddlers and will not
contribute to autonomy. Children at this age engage in parallel play. This will not foster
autonomy.
Which nursing instruction is appropriate when teaching parents of toddlers about how to prevent
poisoning?
Keep ipecac in the home.
Consistently use safety caps.
Store poisonous substances out of reach.
Store poisonous substances in a locked cabinet.
Rationale
Safe storage of poisonous substances is an appropriate way to prevent the curious toddler from
getting into them. Not all poisonous substances have safety caps, and safety caps are not always
foolproof. Ipecac does not prevent poisoning and is not recommended as a treatment for
poisoning. Toddlers can climb and are curious; therefore storing substances out of reach only
does not eliminate the potential for poisoning.

Which developmental delay is present in the 18-month-old child that can say 4 to 6 words, build
a tower of 4 cubes, and throws occasional temper tantrums?
Language
Fine motor
Gross motor
Socialization
Rationale
An 18-month-old child should be able to say 10 or more words. Therefore this child's language
development is delayed. The ability to build a tower of four cubes is normal for the child's age
and indicates normal fine motor skill development. Pulling a toy shows normal gross motor
development for this age. Temper tantrums and showing signs of ownership by saying "my toy"
are normal indications of socialization development at 18 months.

Which information about early childhood caries is appropriate for parents?

This syndrome can be completely prevented by breastfeeding.
Giving the child juice in the bottle instead of milk at bedtime prevents this syndrome.
Giving a bottle of milk or juice at naptime or bedtime predisposes the child to this syndrome.
This syndrome is distinguished by protruding upper front teeth, the result of sucking on a hard
nipple.
Rationale
Sweet liquids, or the sugars in milk and even breast milk, pooling in a toddler's mouth during
sleep increase the incidence of early childhood caries. Changes in the positioning of the teeth
may result from pacifier use or thumb sucking and are not related to bottle-mouth caries.
Frequent breastfeeding before sleep can cause bottle-mouth caries, because breast milk does
contain lactose, which is present in higher concentrations than in cow's milk–based formula.
Juice, which contains varying concentrations of sugar in bottles, contributes to bottle-mouth
caries when a child is allowed to have a bottle of it before sleep.

Which information would the nurse give to parents of toddlers about the regular use of
fluoridated water or beverages that contain fluoride?
All fluoridated water is toxic to children.
These drinks can cause stains or pits in the teeth.
Regular use of fluoridated water is recommended for toddlers.
It is not necessary to check the fluoride level in your water supply.
Rationale
Parents should be cautioned that regular use of fluoridated water or beverages such as bottled
water containing fluoride can result in staining or pitting of the child's teeth. Fluoridated water is
not toxic to children. Regular use of fluoridated water is not recommended for toddlers.
Supplementation based on fluoride concentration of water supply less than 0.3 ppm (parts per
million) is 0.25 mg for a child 6 months to 3 years of age and 0.5 mg for a child 3 to 6 years of
age, according to the American Academy of Pediatric Dentistry.

Which statement by the parent indicates to the nurse that the parent needs more instruction
regarding accident prevention?
"We locked all of the medicine in the medicine chest."
"We turned down the temperature on our water heater."
"We put gates at the top and bottom of the basement steps."
"We put our child in a seat belt now that our child is older."
Rationale
A car seat should be used until the child weighs 18 kg (40 lb) and is approximately 4 years old.
Locking up medicines and any other harmful household products, turning down the thermostat
on the water heater, and placing gates at the top and bottom of the basement stairs are all
appropriate actions, and so there is no need for further instruction.

Which nursing advice is appropriate for the parents of a toddler with sleep problems?
Vary the bedtime ritual.
Explain away the child’s fears.
Use a transitional object at bedtime.
Restrict stimulating activities throughout the day.
Rationale
Transitional objects may help ease the toddler's anxiety and facilitate sleep. A consistent set of
bedtime rituals will facilitate a toddler's sleep. Toddlers should engage in stimulating physical
activity during the day to help them sleep at night. Toddlers do not understand verbal
explanations, so parents cannot explain away their fears.

Which behavior is described when a 2½-year-old child angrily says to the chair: "Why you push
me?"
Animism
Centration
Transduction
Inability to conserve
Rationale
Attributing life-like qualities to inanimate objects is called animism; therefore this child is
exhibiting animistic behavior. Centration is focusing on one reason rather than thinking about all
possible alternatives. A child refusing to eat a particular food because of its color although the
taste of the food is good is an example of centration. Transductive behavior is reasoning from
specific cases to specific cases. If a child refuses to eat food because the previously eaten food
did not taste good, the child exhibits transductive behavior. Inability to conserve is the inability
to understand the idea that mass can be changed in size or shape without adding anything to the
original mass.

Which explanation is appropriate for the toddler's attachment to a favorite blanket?

It encourages immature behavior.
The blanket is an important transitional object.
The child and mother have inadequate bonding.
The developmental task of individuation-separation has not been mastered.
Rationale
The blanket is an important transitional object that provides security when the child is separated
from the parents. Transitional objects are important in helping toddlers separate, and attachment
to them does not indicate immature behavior. Transitional objects are helpful when a toddler
experiences increased stress, such as during hospitalization. The attachment to the blanket does
not reflect inadequate bonding with the mother.

Which factor is appropriate to consider when starting toilet training in the toddler?
Consistency in approach
Positive attitude of the mother
Developmental readiness of the child
Developmental level of the child’s peers
Rationale
If the child is not ready developmentally, it would be frustrating for both the parent and the child
during toilet training. Consistency in approach is important once toilet training has already
started. A positive attitude from the primary caregivers is also important once the child is ready
for toilet training. Developmental levels are different for every child, and comparison with peers
is not appropriate.

Which nutrient’s absorption is increased by vitamin C?

Iron
Calcium
Magnesium
Phosphorus
Rationale
Vitamin C increases the absorption of iron. Vitamin C does not increase the absorption of
calcium, magnesium, or phosphorus.

Which condition would the nurse be concerned for in the toddler that drinks milk and fruit juice
and consumes little solid food?
Rickets
Iron deficiency
Phosphorous deficiency
Amino acid deficiency
Rationale
Milk is a poor source of iron, and if the child drinks mostly milk, it may lead to iron deficiency.
Rickets is caused by vitamin D deficiency. Milk is a chief source of calcium and phosphorous.
Amino acids are found in milk and milk products.
Which statement by the nurse is appropriate regarding the child throwing a tantrum after having
a toy taken away that is usually given when the parent is away?
Give the toy to the child to minimize loneliness.
Avoid giving the toy to the child when the parent is not there.
Toys cannot give security to the child when the parent is away.
Attachment to toys is a psychologic problem and is to be avoided.
Rationale
A favorite toy or blanket can provide security to a child when separated from the parents and
dealing with new stress or fatigue. Such objects are called transitional objects. Toddlers get
attached to such objects and often refuse to give them to someone else. This kind of behavior is
normal and should not be discouraged. Therefore the parent should be allowed to give the toy to
the child. The nurse would not give false information to the parent that the toy does not provide
any security to the child and should not discourage the parent from giving toys. Attachment to
toys is normal and does not indicate a psychologic problem.

Which age is the behavior of domestic mimicry appropriate?

13 months
15 months
24 months
32 months
Rationale
Domestic mimicry is observed in children who are 19 to 24 months old, which is the final stage
of the sensorimotor stage. Children are aware of other people’s actions, and they attempt to copy
them at this sensorimotor stage. Children who are 13 to 15 months old are in the fifth
sensorimotor stage. Domestic mimicry is not a behavior of children in this stage. Children who
are 32 months old are in the preoperational phase; in this stage, increased use of language and
mental symbolization is observed.

Which condition is the 18-month-old child at risk for when prolonging bottle-feeding?
Iron deficiency
Sleep problems
Early childhood caries
Delayed language development
Rationale
Prolonged bottle-feeding may cause a type of tooth decay called early childhood caries, which
mostly affects the upper incisors and molars. Delayed language development is caused by other
factors, such as exposure to television constantly before the age of 24 months or other cognitive
impairments. The child is at risk for iron deficiency if the child does not consume iron-enriched
foods. Sleep problems are due to factors such as fears, awareness of separation, or heavy meals
before bedtime.

Which activity is appropriate to improve the language skill of the child?

Reading books together
Watching one DVD together
Playing computer games together
Allowing the child to watch television
Rationale
Reading books together with the child enables language development. Computer games do not
respond to children’s ideas even though children love playing them; therefore children should be
restricted from playing them. Television also does not interact or respond to the child. Moreover,
the American Academy of Pediatrics suggests that children under the age of 2 years should not
be allowed to watch television.

Which characteristics of preoperational thought are appropriate in toddlers?

Considering all possible alternatives
Ability to see the event or object from another perspective
Ability to understand that something can be different than the way it appears
Belief that their thoughts are all powerful and caused the event that occurred
Rationale
Children who use preoperational thought believe that their thoughts are all powerful and can
cause the event that occurred, otherwise known as magical thinking. Centration, a term given to
preoperational thought, means that toddlers are unable to consider all possible alternatives. They
are unable to see the event or object from another perspective because of their egocentrism. They
do not have the ability to understand that something can be different than the way it appears to
be, also known as the inability to conserve.

Which statement is correct with regard to the safety of toddlers in car restraints?
The front seat is the best place for toddlers.
Restraints are used until the age of 7 years.
The seat belt should be worn on the abdominal area.
The shoulder belt is used if it does not cross child’s neck or face.
Rationale
Shoulder belts are used for toddlers only if they do not cross the child’s neck or face, which may
lead to choking. The backseat is the safest area in the car for children. Car restraints are used for
children until they are 12 years of age. Seat belts should not be worn on the abdomen; they
should be worn low on the hips and fit snugly.

Which recommendation is appropriate to provide to the parents of toddlers about car restraints?
Use car restraints even for short trips.
Add extra head cushions for comfort.
Discourage the toddler from holding a toy.
Add padding between the child and the restraint strap.
Rationale
Car restraints should be used even for a short trip to provide safety to the toddler. Adding an
extra head cushion for comfort should be avoided, because this creates spaces between the child
and the restraint, and decreases support to the head. Encouraging the toddler to hold a favorite
toy will help the toddler to play quietly. Adding any padding between the child and the restraint
strap should be discouraged, because it will create space between the child and the restraint. This
will result in decreased support to the back of the toddler.
Which behavior is appropriate when describing the child that will "only eat crackers, cheese, and
turkey?"
Ritualism
Regression
Negativism
Abnormal behavior
Rationale
Ritualism is common in toddlers, who often go on food jags during which they insist on having
the same foods, same dish, same cup, or same spoon. In regression there is a retreat from one's
current pattern of function to a past level of behavior; it has nothing to do with a toddler's food
patterns. Negativism is the toddler's answer of no to every request; it is not associated with only
eating certain foods. Eating only crackers, cheese, and turkey is not abnormal behavior for a
toddler.

Which behavior is appropriate when describing a preschool-age child that after having a sibling
born is using baby talk and wants a bottle?
Neglect
Regression
Acceptance
Resentment
Rationale
The child uses regression to reduce the stress that the child feels after the birth of the new infant.
Regression is a retreat from a present pattern of functioning to past levels of behavior. It usually
occurs in instances of stress, when one attempts to cope by reverting to patterns of behavior that
were successful in earlier stages of development. The child is not neglected by the parents;
instead the attention that the new infant receives may be considered by the older child as
threatening. The child is not trying to accept the baby; instead the child is manifesting jealousy
towards the baby. The child does not resent the baby, but does not like the new changes that are
caused by the arrival of the infant.

Which nursing advice is appropriate when explaining proper restraint of toddlers in motor
vehicles to a group of parents?
Fitting the seat belt snugly over the toddler's abdomen
Placing the car seat in the back seat of the car, facing forward
Using lap and shoulder belts when child is over 3 years of age
Placing the car seat in the front passenger seat if there is an airbag
Rationale
Car seats are required for toddlers to prevent injury in case of a motor vehicle accident. The car
seat should be placed in the back seat, facing forward. A seat belt can cause injuries if it is placed
over a toddler's abdomen. Car seats should be placed in the rear of the car because airbags can
injure the toddler. Three-year-old children should be restrained in car seats.

Which nursing action is appropriate when a toddler refuses pasta because it does not taste good
and when offered a banana immediately after, will not try it?
Give the banana to the child later.
Inform the pediatrician about the child's behavior.
Tell the child that a banana is different from pasta.
Force the child to eat the banana now to avoid hunger.
Rationale
A toddler may refuse to eat something when a previous food did not taste good. This type of
reasoning is called transductive reasoning. In such situations the nurse should accept the
response and offer the refused food at a later time. It is not necessary to inform the pediatrician at
this stage. The nurse should never force-feed a child. Telling a toddler that a banana is different
from pasta will not necessarily be helpful, because this sort of reasoning may not be understood
by the child.

Which age is the child able to distinguish finger and spoon foods and chews food with mouth
closed by moving food inside the mouth?
12 months
16 months
18 months
24 months
Rationale
Toddlers who are 24 months old will be able to distinguish between finger food and spoon food;
therefore this is the age of the child. They chew food with their mouth closed and are able to
move the food inside the mouth. Toddlers who are 12 to 18 months old are able to hold and drink
well from a cup with a lid, and drop it when finished.

Which nursing advice is appropriate regarding children that touch their genitalia in public?
Do not allow children to play with genitalia in public or private places.
Teach that genital stimulation in private is acceptable but not in public.
Take these children to a psychologist or psychiatrist for a health checkup.
Ignore it, because it is a normal phenomenon in psychosocial development.
Rationale
Activities of a toddler should be dealt with carefully because reactions of parents influence the
attitudes of children and can affect their psychosocial development. It is a normal phenomenon
for toddlers to stimulate their genital organs, but they should be taught that such activities are not
accepted in public places and should be done in private. At this stage parents need not consult a
psychologist or psychiatrist for a health checkup of the toddler. However, it is also inappropriate
to ignore such behavior.

Which nursing response is appropriate when asked why toddlers throw tantrums?
"Tantrums occur when toddlers are hungry or very tired."
"Tantrums are often a result of sleep deprivation and fatigue."
"Tantrums are a consequence of poor parenting and inadequate discipline."
"Tantrums result from a toddler's strong drive for mastery and autonomy."
Rationale
Tantrums occur during toddlerhood because of a toddler's strong drive for mastery and
autonomy, but inability to achieve these things due to a lack of motor or cognitive skills and
frustration with adult figures. Although sleep deprivation and hunger can make tantrums more
likely to occur, they do not explain to the parent the underlying cause of tantrums in toddlers.
Rather than stating that tantrums are the result of poor parenting and inadequate discipline, the
nurse should give a more appropriate and therapeutic explanation that includes the need for
parental consistency and appropriate expectations.

Which developmental tasks would a 24-month-old child be able do? Select all that apply.
Name many colors
Refer to self by name
Tell first and last name
Dress self in simple clothing
Recognize gender difference
Rationale
A 24-month-old child will be able to refer to self by name and would say the first name when
asked. The child would also be able to dress in simple clothing. A 30-month-old child would be
able to name many colors, give the first and last name, and refer to self by the appropriate
pronoun. The 30-month-old would also be able to recognize gender differences and as well as
one’s own gender.

Which developmental behaviors does an 18-month-old child possess? Select all that apply.
Possessive of own toys
Imitates sounds of animals
Fits smaller objects into each other
Places square objects exactly in a hole
Opens door and drawers to find objects
Rationale
Tertiary circular reactions are observed in children who are 13 to 18 months old. Tertiary circular
reactions are schemes in which an infant purposely explores new possibilities with objects,
continually changing what is done to them and exploring the results. Children in the fifth
sensorimotor stage, or tertiary circular reactions, would possess the ability to fit smaller objects
into each other. They open doors and drawers to find objects and have object permanence,
indicating they are able to realize that objects out of sight are not out of their reach. Children in
the preoperational stage, which ranges from about ages 2 to 4, are found to be possessive of their
own toys, and they use the word "mine." Children in this stage can mentally represent events and
objects and engage in symbolic play. Children in the sixth sensorimotor stage, or the stage in
which the child invents new means through mental combinations, imitate sounds of animals and
words of adults. This stage ranges from about ages 19 to 24 months. Children in the fifth
sensorimotor stage can place a round object into a hole exactly, but they cannot do so with a
square until they are 2 years old.

Which action would be avoided in order to control stress in the toddler?

Giving drums to play
Using imagery technique
Increasing the rest period
Encouraging supervision during play
Rationale
The parents should avoid supervising the toddlers while they are playing; this will help in
controlling stress in toddlers. Playing with drums and a toy nail and hammer will help the toddler
to cope with stress. Using imagery and relaxation techniques will help the toddler in controlling
stress. Increasing the rest period of the toddlers is an effective way of controlling stress.

Which statement made by the mother regarding minimizing sibling rivalry with the toddler needs
further learning?
"A new playmate will come home soon."
"I will read stories for you and the baby."
"I will take you and the baby to the park."
"We have to feed the baby when the baby comes home."
Rationale
Toddlers need to have a realistic idea about what will happen when a new baby comes home.
Therefore an unrealistic expectation will be set when the mother says that a new playmate will
come home soon. The mother needs to emphasize that things such as reading stories and going to
the park will not change once the baby arrives. Parents should also stress activities such as
bottle-feeding to the toddler so that the child has a realistic idea of what to expect once the
newborn arrives.

Which nursing instruction is appropriate to help prevent dental caries in a family's

toddler? Select all that apply.
Using the bottle as a pacifier
Coating pacifiers in apple juice
Eliminating the bedtime bottle
Never putting juice in the bottle
Substituting a bottle of water for milk or juice
Rationale
The nurse should educate the families of toddlers of the need to help prevent dental caries by
eliminating the bedtime bottle, substituting a bottle of water for juice, never coating pacifiers in
sweeteners or juice or using the bottle as a pacifier, and refraining from putting juice in the
bottle.

Which nursing response is appropriate for the parent of an 18-month-old child that eats nothing
on some days and a lot on other days?
"This is a normal phenomenon at this age. Your child is fine."
"Is the child taking any medications for any sort of health problems?"
"The child needs to be admitted into the hospital immediately for treatment."
"The child may need some blood tests because there is a problem with the gastrointestinal (GI)
system."
Rationale
Most toddlers at 18 months of age have decreased nutritional needs, manifested as decreased
appetite. This phenomenon is called physiologic anorexia. During this stage they become fussy
eaters with strong taste preferences, and they may eat nothing one day and large amounts the
next day. Therefore the parent should be informed that this is normal, and the child is fine. This
phenomenon is not caused by medications. The parent should be reassured that the child has no
health issues and does not require any treatment at a hospital.

Which place in the birth order are feelings of sibling rivalry most pronounced?
Middle
Firstborn
Youngest
Second born
Rationale
Firstborn children experience dethronement and therefore tend to have the most pronounced
sibling rivalry. Second born children do not have the most pronounced sibling rivalry. Middle
children do not experience as difficult a time with sibling rivalry as firstborn children. Firstborn
children, rather than youngest children, have more pronounced sibling rivalry.

Which action by the toddler indicates delayed fine motor development? Select all that apply.
Cannot build a block tower.
Unable to draw circles on paper.
Unable to release an object at will.
Loses balance while throwing a ball.
Cannot drop objects into a narrow-necked bottle.
Rationale
At 15 months of age, the child can grasp and release an object at will. The toddler is able to build
a block tower at the age of 24 months. The toddler can throw a ball without losing balance at 18
months. The toddler can drop objects into a narrow-necked bottle at the age of 15 months. The
child is able to draw circles on paper from the age of 36 months.

Which instructions are appropriate when recommending fluoride supplements for the toddler?
Give fluoride supplements after breakfast.
Give fluoride supplements along with milk.
Administer supplements at a convenient time.
Store fluoride supplements away from the toddler.
Rationale
Fluoride supplements should be stored at a place where the toddlers cannot reach them, because
accidental excess consumption of fluoride leads to fluorosis. Fluoride supplements should be
provided on an empty stomach. Fluoride supplements should not be given along with calcium-
rich products such as milk. Fluoride supplements should be administered at the same time each
day.

Which nursing instruction is appropriate when teaching parents about injury prevention at the
toddler's well-child visit? Select all that apply.
Put matches out of reach.
Supervise the child while playing outside.
Turn pot handles toward the back of the stove.
Never leave the child unsupervised in a bathtub.
Make the child wear a seat belt when sitting in the front passenger seat.
Rationale
The nurse would teach parents about injury prevention at the toddler's well-child visit. Such
information includes the need to put matches out of reach; the need to supervise when the child
plays outside; turning pot handles toward the back of the stove; and to never leave the child
unsupervised in a bathtub. The nurse would teach the parents that the safest place in the car for a
toddler is in an appropriate car seat in the back, not the front, seat of the vehicle.

Which nursing advice is appropriate for the parents of a 2-year-old who resists going to bed,
cries, and bangs the head against the wall?
During temper tantrums, ignore the behavior of the child.
Do not tell stories to children who throw tantrums before bedtime.
Never be lenient with the child; otherwise, tantrums will become a habit.
Praise the child after the temper tantrum for any positive, appropriate behavior.
Rationale
Temper tantrums are common in children, but if the child is banging the head against the wall,
the parent should not ignore this behavior, because the child could be injured. After the tantrum
ends, the parent should reinforce any positive behavior of the child by praising or by giving a
reward. The child should not be punished during or after tantrums. Telling stories to the child at
bedtime can also be useful.

Which nursing action is appropriate when a 2-year-old child has been having temper tantrums,
during which the child halts breathing and occasionally faints?
Referring the child for a respiratory evaluation
Explaining to the parent that this is not harmful
Explaining to the parent that the child is spoiled
Referring the child for a psychologic evaluation
Rationale
The rising carbon dioxide level restarts the breathing process when a child holds the breath;
therefore the process is self-limiting and not harmful. A respiratory evaluation is not indicated
for this toddler. Temper tantrums are part of this developmental stage as the toddler asserts
independence; there are no data to indicate that this child is spoiled. A psychologic evaluation is
not warranted.

Which nursing advice would be appropriate regarding the nutritional needs of the child during a
growth spurt? Select all that apply.
Select all that apply
Plan a nutritionally balanced day.
Plan a nutritionally balanced week.
Serve food in various physical forms.
The toddler shouldn't smell a new food.
Feed the child while the child is actively playing.
Rationale
Toddlers try to control their environment as they grow. Parents should be advised to plan for a
nutritionally balanced week. By serving food in different forms and shapes, "food jags" can be
prevented. New food should be introduced in a stepwise pattern, such as having the child smell,
touch, taste, and then eat the new food. Feeding the toddler while actively playing can cause
choking and is not recommended.

Which instructions would the nurse give parents during discharge following an accidental
swallowing of a foreign body? Select all that apply.
Cut fruits in small pieces.
Give toys with removable parts.
Give marshmallows or chewing gum.
Avoid contact with small plastic balls.
Slice hot dogs lengthwise into short pieces.
Rationale
A toddler can swallow hard or inedible pieces of food, which can lead to choking and
suffocation. Therefore parents would be advised to avoid the child's contact with small plastic
balls. Big pieces of fruits may cause choking; therefore fruits should be cut into small pieces
before giving them to the child. Foods such as hot dogs should be cut lengthwise into short
pieces. Parents should not allow toys with removable parts and should not give chewing gum or
marshmallows to their children.

Which nursing advice is appropriate when preschool children refuse to sleep in their own bed?
"Keep the television on when children sleep."
"Punish children who refuse to sleep in their own bed."
"Allow children to hold their favorite toy when sleeping."
"Parents may lie in the bed with children and talk with them until they fall asleep."
Rationale
Parents would allow children to hold a favorite toy when sleeping, because this provides security
to the child and helps the child deal with the new stress of being separated from parents. Parents
would not punish children for refusing to sleep in their own bed. Instead, parents can reward
children in the morning for sleeping alone in bed. Television should be switched off when
children sleep because the light from the television screen makes it difficult for them to fall
asleep. The room should be kept dark while sleeping, because the brain is stimulated to produce
sleep hormones when the room is dark. Night-lights can be kept on, if required. Parents would
avoid lying in bed with children and avoid interacting with children until they fall asleep to
reduce dependence on the parent at night.

Which approach is appropriate when handling a toddler who, after the birth of a sibling, wants to
drink from a bottle and demands the same toys as the new baby?
Ignore this behavior and praise appropriate behavior.
Teach the toddler new skills for further development.
Take the toddler to a psychologist for behavioral therapy.
Refer the toddler to an experienced psychiatrist for a checkup.
Rationale
The behavior of the child indicates regression, which means retreat from present behaviors to
behaviors adopted as a baby. It is common in toddlers when they face additional stress such as
illness or adjustment to a new sibling. During this time the toddler needs understanding and
patience from the parents and caregivers. Therefore the best approach is to ignore regressive
behavior and praise appropriate behavior. Learning new skills causes additional stress and is not
advised. Regression is not a psychologic disorder, and there is no need for behavioral therapy or
a health checkup by a psychiatrist at this stage.

Which parent action indicates a requirement for further learning from the nurse regarding temper
tantrums?
Not talking to the child.
Taking the child out daily.
Praising the child for positive behavior.
Comforting the child once the tantrum subsides.
Rationale
The parent should offer the child a choice during a temper tantrum rather than simply not talking
to the child. Taking the child out for a while will help in managing temper tantrums, especially
during bedtime. The parent should praise the child for positive behaviors, so that it helps manage
temper tantrums. Once the temper tantrum subsides, the parent should comfort the child so that
the child will feel secure.

Which statement is appropriate with regard to temper tantrums in toddlers?

Lasting for 5 minutes is normal.
Normally appear 10 times a day.
Appearing for 20 minutes is normal.
Normally appear until 10 years of age.
Rationale
Temper tantrums in toddlers lasting for 5 minutes are normal. Temper tantrums occur when the
child is ill, hungry, frustrated, or tired. Temper tantrums appearing 5 times a day, appearing in
children over 5 years of age, and lasting for more than 15 minutes are indications of serious
problems. The health care provider should be notified immediately if any of these situations take
place.

Which finding in the home should be addressed by the nurse?

Presence of a carbon monoxide detector
Placing of an old refrigerator with the doors removed
Openings of 3 inches between the railings in a balcony
Placing of cough syrup in a child-proof container at a high level
Rationale
It is important for a nurse to give appropriate instructions to the parents to prevent any accidental
injuries to toddlers at home. Toddlers are often able to remove child-proof containers and can
access high-level, tight-security areas. They try to explore things by tasting them and therefore
can ingest cough syrup, which could lead to poisoning. Parents should be advised to lock such
containers or medicines in a cabinet where the child is unlikely to see them. Most toddlers cannot
pass through an opening of 4 inches or less. It is important to have a carbon monoxide detector in
homes where the heating system is old. Parents should be advised to remove the doors of old
appliances such as refrigerators or ovens before storing them or discarding them to prevent
accidental trapping of their toddlers.

Which nursing advice is appropriate when addressing a 26-month-old child that refuses to use
the potty?
"Force the child to sit on the potty for 30 minutes."
"It is too early for to start toilet training for the child."
"Make up a game to encourage the child to use the potty."
"Give lactulose in the morning and place the child on the potty."
Rationale
The parent should make up a game to encourage the child to use the potty, and make toilet
training easy and as simple as possible. Forcing the child to sit on the potty will not support the
child’s sense of control. At 26 months old, the child is at the appropriate age for toilet training.
Children attain voluntary control of anal and urethral sphincters usually when they are 22 months
old. Lactulose is a laxative. Laxatives should not be given to children unless prescribed by a
physician.

Which condition is the 18-month-old child at risk for when prolonging bottle-feeding?
Iron deficiency
Sleep problems
Early childhood caries
Delayed language development
Rationale
Prolonged bottle-feeding may cause a type of tooth decay called early childhood caries, which
mostly affects the upper incisors and molars. Delayed language development is caused by other
factors, such as exposure to television constantly before the age of 24 months or other cognitive
impairments. The child is at risk for iron deficiency if the child does not consume iron-enriched
foods. Sleep problems are due to factors such as fears, awareness of separation, or heavy meals
before bedtime.

Which description characterizes toddlers' eating behavior?

They are fussy eaters.
The have increased appetites.
They have few food preferences.
Their table manners are predictable.
Rationale
Toddlers have physiologic anorexia, which contributes to picky, fussy eating (not an increased
appetite). This usually begins around 18 months of age. Children also have strong taste
preferences at this age. Use of finger foods contributes to the unpredictable table manners of
toddlers.

Which child would need fluoride supplementation?

4 months of age
5 months of age
6 months of age or older
Fluoride supplementation is not recommended for infants.
Rationale
Fluoride supplementation is recommended for children 6 months or older whose drinking water
is deficient in fluoride. Fluoride supplementation is not recommended at 4 or 5 months of age.

Which term is appropriate when describing the phenomenon at work when a toddler separates
from the mother and begins to make sense of experiences in the environment but is then drawn
back to the mother for assistance in verbally articulating the meaning of these experiences?
Gender identity
Rapprochement
Transitional objects
Mental symbolization
Rationale
Rapprochement is defined as the phenomenon of a toddler's separation from the mother and
beginning to make sense of experiences in the environment, followed by a drawing back to the
mother for assistance in verbally articulating the meaning of these experiences. Gender identity
is defined as a sense of maleness or femaleness. Transitional objects, such as a favorite blanket
or toy, provide security for children, especially when children are separated from their parents,
dealing with a new stress, or just fatigued. Mental symbolization is associated with prelogical
reasoning, in which painful experiences take on new significance because memory is associated
with the specific event.

Chapter 13
A mother tells the nurse that her daughter's favorite toy is a large empty box that contains a
stove. She plays "house" in it with her toddler brother. The nurse, drawing on knowledge of
growth and development, recognizes this as what type of action?
Suggestive of limited family resources
Suggestive of limited adult supervision
Unsafe play that should be discouraged
Creative play that should be encouraged
Rationale
This type of play should be encouraged. After children create something new, they can then
transfer it to other situations. There should be some supervision to prevent injury or accidents.
As long as the play is supervised, it should be encouraged. This is not considered unsafe play.
There is no indication of limited resources or of limited adult supervision.

Parents tell the nurse that they are concerned about their 4-year-old child's fear of the dark. How
would the nurse teach the parent to respond to normal preschool fears?
To invalidate the child's fears so the child understands that there is no need to be afraid
To force the child to confront the frightening experience in the presence of the parents
To actively involve the child in finding practical methods to deal with the frightening experience
To use logical persuasion to explain away the child's fears and help the child recognize how
unrealistic the fear is
Rationale
Actively involving preschoolers in finding methods to deal with frightening experiences is the
best way to deal with fears in preschoolers. Invalidating the child's fears so the child understands
that there is no need to be afraid will make the fears worse. Forcing a child to confront fears may
make the situation worse. Using logical persuasion to explain away their fears and help the child
recognize how unrealistic it is will not work for preschoolers, who employ preconceptual
thought.

The parents report to the nurse that their preschooler watches television for about 9 hours a day.
What will the nurse advise the parents related to television and their child?
Set limits for television viewing.
Force the preschooler to read books.
Give strict punishment to the preschooler.
Avoid allowing the preschooler to watch television.
Rationale
Watching television may have potential negative effects on preschoolers; therefore watching it
should be limited. Parents should supervise the selection of programs and watch and discuss
programs with their children. Strict punishment should be avoided because it may lead to
psychologic problems later in life. Preschoolers should not be forced to read books, because they
may not enjoy them unless they can read them by themselves, which requires self-motivation.
Gentle persuasion should be used instead. Preschoolers should not be completely prevented from
watching television, because they may gain knowledge from the educational programs.

A preschooler asks the parent, "Where did I come from?" How would the parent ideally react to
the child's question?
Scold the child
Change the subject
Offer sex education
Explain the origin of birth
Rationale
The parents should explain the origin of birth because preschoolers are curious about this and
many other things. While answering, the parents should find out what their preschoolers already
know and think about this subject. Changing the subject is not effective, because children will
ask again later. Avoid scolding preschoolers, because this causes fear. Preschoolers are too
young to understand sex education, so this should be avoided until the child is older.

The nurse is assessing a child and finds that the child's permanent teeth have started erupting.
The child is able to balance on alternating feet with the eyes closed and is able to follow
commands in succession. What is the approximate developmental age of the child?
2 years
3 years
4 years
5 years
Rationale
The approximate age of the child can be determined by assessing the activities performed by the
child, which give an indication of growth and development. Permanent teeth usually start
erupting by 5 years of age. Motor capabilities are well-developed; therefore the child is able to
balance on alternating feet with eyes closed and can follow commands in succession. A 2-year-
old child is not able to balance on alternating feet. A 3-year-old child can ride a tricycle, but
physical balance is difficult while dancing. A 4-year-old child can walk down stairs using
alternate footing and can begin to comprehend analogies.

The nurse is educating working parents of a preschooler about daycare centers. What statement
by the parents indicates that they need additional teaching about daycare centers?
Daycare centers help increase self-confidence of preschoolers.
Daycare centers help preschoolers adjust to sociocultural differences.
Daycare centers expose preschoolers to opportunities to learn group cooperation.
Preschoolers who attend daycare centers are healthier than those who stay at home.
Rationale
Preschoolers in daycare centers have more illnesses than children at home. There is a high
possibility of acquiring hepatitis A, varicella-zoster virus, gastrointestinal tract infections, and
respiratory tract infections in daycare centers due to lack of sanitation. One can be more sure
about hygiene at home than in daycare centers. There are some advantages to daycare centers,
such as that they increase self-confidence in the child, help children adjust to sociocultural
differences, and expose children to opportunities for learning group cooperation.

What is the term used to describe the attribution of lifelike qualities to inanimate objects?
Animism
Stress
Frustration
Desensitization
Rationale
Animism is the term used to describe the attribution of lifelike qualities to inanimate objects.
Neither stress nor frustration is the term used to describe the attribution of lifelike qualities to
inanimate objects. In desensitization, children are exposed to the object they fear in a safe
situation.

The parents of a 5-year-old child are worried because the child stutters when speaking. On
examination the nurse finds that the child has no problem with hearing. What would the nurse
tell the parents?
"A deviated nasal septum may be one of the causes of stuttering in children."
"Stuttering is common at this age and usually resolves during late childhood."
"Stuttering typically happens due to poor vocabulary and hearing difficulties."
"The vocal cords are inflamed and infected with bacteria, and require antibiotics."
Rationale
Stuttering is common during the age group of 2 to 5 years. This is the period when children
speak faster than they can produce the words. This failure of sensorimotor integration leads to
stuttering. However, parents should be reassured that it usually resolves in childhood. Stuttering
is more common in boys than girls. It is not caused by bacterial infection, deviated nasal septum,
or hearing problems.

A mother tells the nurse that she is concerned because her 3-year-old son has recently started
talking about an imaginary friend named Gus. What information is appropriate for the nurse to
address the mother's concern?
The appearance of imaginary companions is common among 3-year-olds.
The appearance of imaginary companions is worrying in a child at any age.
The appearance of imaginary companions is common among 5-year-olds entering school.
The appearance of imaginary companions would not be unusual for a 3-year-old boy with older
siblings.
Rationale
The appearance of imaginary companions is common among 3-year-olds. Imaginary companions
are not common among 5-year-olds because these companions tend to disappear when the child
enters school. The appearance of imaginary companions is not a matter of concern in a young
child. The appearance of imaginary companions would be less common in a 3-year-old who has
older siblings than in one who does not.
A 7-year-old child still does not have a sense of justice and fairness and judges whether an action
is good or bad according to if it results in reward or punishment. In which stage of moral
development is the child?
Electra complex
Oedipus complex
Instrumental orientation
Punishment and obedience orientation
Rationale
During 2 to 4 years of age, children judge whether an action is good or bad according to whether
it results in reward or punishment. This stage of moral development in the child is known as
punishment and obedience orientation. The 7-year-old child who still judges whether an action is
good or bad according to whether it results in reward or punishment is stuck in the punishment
and obedience orientation phase of moral development. Electra and Oedipus complexes are
phases of psychologic development in boy and girl children. They are not related to moral
development. By 7 years of age, children have a concrete sense of justice and fairness and are in
the instrumental orientation of moral development.

During an assessment the nurse finds that a child has poor muscle coordination. What instruction
does the nurse provide the parents to help develop muscle coordination in the child?
Compel the child to eat food.
Restrict the child from skating.
Encourage the child to swim.
Encourage the child to play with flash cards.
Rationale
Swimming helps in developing muscle coordination in the child and promotes physical growth
and refinement of motor skills. Therefore the parents should encourage the child with poor
muscle coordination to swim. Compelling a child to eat may not help in the development of
muscle coordination. The child should be encouraged to skate, because it helps in developing
muscle coordination. Playing with flash cards is helpful for fine motor development and self-
expression but may not help improve muscle coordination.

What is the best approach to effective communication with a preschooler?

Play
Action
Speech
Drawing
Rationale
Preschoolers' most effective means of communication is play. Play allows preschoolers to
understand, adjust to, and work out life's experiences through the imagination and ability to
invent and imitate. Actions are not an appropriate means of communication for a preschooler.
Speech is not effective because preschoolers assume that everyone thinks as they do and that a
brief explanation of their thinking makes them understood by others, which is often not true.
Also, preschoolers often do not understand the meanings of words and often take statements
literally. Drawing is still being developed as a fine motor skill; therefore it is not the most
effective means of communication.
The parents report to the nurse that their child avoids going out of the house due to fear of dogs.
What teaching would the nurse provide the parents to help them reduce their preschooler's fear?
Avoid any contact with dogs in and outside the home.
Scold the preschooler for being fearful of going outside.
Compel the preschooler to touch the dogs and pet them gently.
Suggest the preschooler observe other children playing with dogs.
Rationale
A variety of real and imagined fears are present during the preschool years. The exact cause of
these fears is unknown. Some preschoolers are fearful of dogs. In such cases the parents should
suggest that the child observe other preschoolers playing with dogs. This type of modeling is
effective in gradually reducing fear. Scolding the preschooler may make the child more fearful.
Avoiding contact with dogs may increase the preschooler's fear. The parents should not compel
the child to touch the dogs, because this may cause more fear.

What is the major task of learning right from wrong that develops toward the end of toddler
years?
Changing body image
Determining sexuality
Cognitive development
Conscience or superego
Rationale
Superego develops toward the end of the toddler years and is a major task for preschoolers. The
development of the superego occurs when the child begins to understand the difference between
right and wrong. Even though children do learn about sexuality and body image as preschoolers,
they have little to do with learning the difference between right and wrong. Children begin to
identify the differences between boys and girls during the preschool years. Body image develops
in preschoolers, wherein the child recognizes differences in skin color and racial identity.
Children do experience cognitive development as they grow older, but it is more apparent toward
the end of the preschool age and the beginning of the school-age phase.

According to Erikson, the primary psychosocial task of the preschool period is developing a
sense of what?
Identity
Initiative
Intimacy
Industry
Rationale
Preschoolers focus on developing initiative. The stage is known as initiative versus guilt. Identity
versus role confusion is associated with adolescence. Intimacy versus isolation is associated with
young adulthood. Industry versus inferiority is associated with the school-age child.

During a well-child visit, the father of a 4-year-old child tells the nurse that he is not certain that
his child is ready for kindergarten. The child's birthday is close to the cut-off date for the start of
kindergarten, and the child has not attended preschool. What is the appropriate recommendation
by the nurse?
Encouraging the father to have the child start kindergarten
Recommending that the father postpone kindergarten and send the child to preschool
Referring the child for developmental screening and making a recommendation based on the
results
Having the father observe a kindergarten class and then deciding whether his child would enjoy
the experience
Rationale
A developmental screening will provide the necessary information to help the family determine
readiness. Encouraging the father to have the child start kindergarten does not address the
father's concern about readiness and suggests that his concerns are not warranted.
Recommending to the father that he postpone kindergarten and send the child to preschool
assumes that the child is not ready for kindergarten, but this recommendation is not based on any
data. Recommending to the father that he simply place his child in preschool may lead to
boredom with school on the part of the child. Having the father observe a kindergarten class and
then decide whether the child would enjoy the experience will provide information about the
kindergarten but not about whether his child is ready to begin and thrive there.

What is the typical way sexual development occurs during the preschool years?
Strong attachments to same-sex friends
Strong attachments to opposite-sex friends
Strong attachment to the same-sex parent and identification with the opposite-sex parent
Strong attachment to the opposite-sex parent and identification with the same-sex parent
Rationale
Sexual development during the preschool years is formed by a strong attachment to the opposite-
sex parent and identification with the same-sex parent. Strong attachments to opposite-sex or
same-sex friends are not characteristic of sexual development during the preschool years. Strong
attachment to the same-sex parent tends to occur in the toddler and infant years.

When preparing parents to teach their preschool child about human sexuality, what would the
nurse emphasize?
A parent's words may have more influence on the child's understanding than do the parent's
actions.
Parents should avoid using correct anatomic terms because they are confusing to preschool-aged
children.
Parents should encourage preschoolers to satisfy their sexual curiosity by playing "doctor."
Parents should determine exactly what the child wants to know before answering a question
about sexuality.
Rationale
It is important that the parent answer the question that the child is asking. Actions may have a
greater influence because language is not fully developed in the preschool years. Using correct
terminology lays the foundation for later discussion of human sexuality. Parents should
encourage children to ask questions to provide accurate information at their cognitive level.

By what age would the nurse expect most children to use sentences of four or five words?
3 years
4½ years
18 months
24 months
Rationale
Children ages 4 to 5 years use sentences of four or five words. An 18-month-old child has a
vocabulary of approximately 10 words. A 24-month-old child uses two- or three-word phrases. A
3-year-old child uses sentences of three or four complete words.

A school nurse observes that children demonstrate mutual play. What is the effect of mutual play
in preschoolers?
It minimizes verbal abilities of preschoolers.
It minimizes language abilities of preschoolers.
It provides kinesthetic experiences for preschoolers.
It reduces interaction between preschoolers and their parents.
Rationale
Mutual play is helpful for the development of motor skills in preschoolers. Through mutual play,
parents can provide kinesthetic experiences for their children. Mutual play encourages positive
interactions between the parent and child and thus strengthens their relationship. It also
maximizes verbal and language abilities.

The nurse is educating parents about growth and development of preschoolers. What instructions
does the nurse give the parents to help them make preschoolers feel comfortable with their body
image? Select all that apply.
Suggest that preschoolers observe others.
Instill positive principles regarding body image.
Restrict the children from communicating with others.
Emphasize the importance of accepting other individuals.
Give the children encouraging feedback regarding their appearance.
Rationale
Preschoolers are aware of the meaning of words such as pretty or ugly. Preschoolers reflect the
opinions of others regarding their own appearance. In this situation the parents should take care
that children do not feel uncomfortable with their body image. The parents should instill positive
principles regarding body image, emphasize accepting people the way they are, and give their
children encouraging feedback regarding their appearance. The parents should not restrict
children from communicating with others, because this can result in loneliness. The parents
should avoid suggesting that children observe others, because comparisons with others may
cause discomfort.

The nurse is educating parents about nutrition in preschoolers. What statement by a parent
indicates that teaching has been effective?
"We will provide a diet with high fat content to the child."
"We will provide fruit juices to the child in higher amounts."
"We will include 13 to 19 g/day of protein in our child's diet."
"We will provide carbonated beverages to our child in higher amounts."
Rationale
Protein requirements increase with age. Recommended intake of protein for proper growth for
preschoolers is 13 to 19 g/day. Avoid providing a higher fat content diet to a child, because this
may lead to obesity. Providing higher amounts of fruit juices may cause dental caries,
gastrointestinal conditions such as chronic diarrhea, and a diet poor in nutritive value.
Carbonated beverages should be avoided because they often contain acid or high amounts of
sugar, which leads to dental cavities.

What activity can be easily performed by the preschooler?

Rope jumping
Roller skating
Swimming
Riding a tricycle
Rationale
A preschooler can easily ride a tricycle due to developed motor abilities. Climbing, jumping,
walking, and running are well established by 3 years of age. A 5-year-old child can perform
activities such as jumping a rope, skating, and swimming. These activities require more muscle
coordination.

What factor or habit of a preschooler does the nurse expect to be responsible for inadequate and
unequal development of the child’s musculoskeletal system?
The preschooler has enough rest.
The preschooler plays travel soccer.
The preschooler has proper nutrition.
The preschooler generally maintains good posture.
Rationale
The proper development of the musculoskeletal system is very important in preschoolers.
Excessive activity and overexertion can injure delicate tissues and be a hindrance for adequate
development. For the preschooler who has inadequate development of the musculoskeletal
system, the nurse would conclude that excessive exercising may be the factor responsible for this
inadequacy. Adequate rest, nutrition, and good posture are essential for the optimum
development of the musculoskeletal system.

What does the preschooler’s body image include?

Fear of intrusive procedures
A well-defined body boundary
Knowledge about internal anatomy
Fear of looking different from friends
Rationale
Preschoolers fear that their insides will come out with intrusive procedures. Preschoolers have
poorly defined body images. Preschoolers have little or no knowledge of their internal anatomy.
The fear of looking different is a concept that occurs in later school-aged children and
adolescents.

The nurse is teaching a group of parents about nutrition, the significance in promoting growth
and development, and avoiding obesity in childhood. What does the nurse include in the
education plan? Select all that apply.
A child should limit protein intake to a minimum of 9 g per day.
The total cholesterol consumption should be less than 300 mg per day.
The fluid intake should be 100 ml per kilogram of body weight per day.
Saturated fatty acid consumption should meet 30% of total caloric intake.
Daily calorie intake should not exceed 90 kcal per kilogram of body weight.
Rationale
Cholesterol consumption in children should not exceed 300 mg per day. Fluid intake should be
approximately 100 ml per kilogram of body weight per day to provide adequate hydration. Daily
caloric intake should be a maximum of 90 kcal per kilogram of body weight for an average daily
intake of 1800 calories to prevent obesity. The recommended protein intake per day should be
between 13 and 19 g for optimal growth rate and muscle building. Saturated fatty acid
consumption should not be more than 10 percent of total caloric intake to avoid coronary artery
disease and diabetes mellitus, among other conditions.

What is accurate information related to the nutritional requirements of preschool children?

The quality of the food consumed is more important than the quantity.
The average daily intake of preschoolers should be about 3000 calories.
Nutritional requirements for preschoolers are different from requirements for toddlers.
The requirement for calories per unit of body weight increases slightly during the preschool
period.
Rationale
It is essential that the child eat a balanced diet with essential nutrients; the amount of food is less
important than the quality of the food. Requirements are similar for both toddlers and
preschoolers. The caloric requirement decreases slightly for preschoolers. The average intake is
about 1800 calories each day for preschoolers.

What fine motor skills can the 3-year-old perform? Select all that apply.
Select all that apply
Copying a circle
Standing on one foot
Lacing up a pair of shoes
Building a tower of nine cubes
Building a bridge with three cubes
Rationale
Three-year-old children can build a tower of nine cubes, copy a circle, and build a bridge with
three cubes. Standing on one foot is a gross motor skill. Lacing up shoes is a fine motor skill that
is expected of a 4-year-old.

A parent of a young child is fearful the child will become overweight. What teaching would the
nurse provide to the parent to prevent obesity? Select all that apply.
Promote eating at restaurants.
Encourage limitation of television viewing.
Encourage 1 hour of physical activity per day.
Limit the consumption of sugar-sweetened beverages.
Encourage the consumption of adequate quantities of fruits and vegetables.
Rationale
Obesity can be prevented by assuming certain lifestyle choices. These include limiting the child's
television viewing. Sedentary activities such as lots of television viewing would increase obesity,
so the nurse should encourage 1 hour of physical activity per day. The nurse should also advise
the patient to limit the consumption of sugar-sweetened beverages, because these can promote fat
deposition. Having frequent family meals in which parents and children sit together helps in
family bonding and healthy eating. Promoting the intake of recommended quantities of fruits and
vegetables helps in eating healthy food and avoiding fattening foods. To prevent the
development of obesity, eating at restaurants should be limited.

What games are helpful in improving self-expression in preschoolers? Select all that apply.
Dramatic play
Imitative play
Imaginative play
Electronic games
Computer games
Rationale
Dramatic, imitative, and imaginative play are helpful for improving self-expression of children.
These games promote development of imagination and improve thinking skills. Electronic games
and computer programs are helpful for learning basic skills, such as letters and simple words.

Parents tell the nurse that their child was recognized in school as "gifted" but are not exactly sure
what that means. The nurse correctly explains to the parents that the common definition of
"gifted" is:
Possessing extraordinary musical or athletic talent
Ranking in the 99th percentile on achievement tests
Having a minimum intelligence quotient (IQ) of 130
Having a minimum intelligence quotient (IQ) of 160
Rationale
Although the definition of gifted varies, giftedness is commonly defined as a minimum
intelligence quotient (IQ) of 130 (not 160). Achievement tests or extraordinary performance
musically or athletically are not the determining factors for being designated as "gifted."

Parents ask the nurse for guidance on how to discuss sex with their preschooler. What is the
appropriate response by the nurse?
Do not restrict children from acting on their sexual curiosity.
Make sure that your child understands that sexual curiosity is a negative behavior.
Find out what your child knows and thinks about sex before answering any questions.
Honesty is not always the best policy when you are trying to protect your child's innocence.
Rationale
Finding out what the child knows and thinks about sex before answering questions is the first
rule of answering sensitive questions about topics such as sex. Making sure that one's child
understands that sexual curiosity is a negative behavior is not appropriate. Allowing children to
act on their sexual curiosity without restrictions only intensifies their anxiety and concern. It is
important to be honest with one's child when answering questions about sex and other sensitive
matters.

Parents tell the nurse that they are worried because their child constantly touches their genitalia
in front of others. What statement by the nurse is appropriate? Select all that apply.
It can occur in any age group.
It is acceptable to do in public.
It is unhealthy if it is excessive.
It is considered a normal behavior.
It is considered sexually perverse.
Rationale
Masturbation or self-stimulation of the genitalia may occur at any age. Masturbation is a healthy
act as long as it is not excessive. It is a normal behavior but should be a private act. Masturbation
is part of sexual curiosity and explorative behavior and not sexual perversion.

During an office visit, parents ask the nurse how to best prepare their preschooler for
kindergarten. What information does the nurse provide to assist the parents? Select all that
apply.
Parents should behave positively and confidently on the first day of school.
Parents should speak of going to school as an exciting and pleasurable experience.
Parents should honestly explain to the children about the need for hard work and discipline to be
successful in school.
Parents should tell the child about activities to look forward to in school such as playing with
children, painting, and building with blocks.
The parents should send their child with an older child to preschool and encourage the child to
make a self-introduction to the teacher and classmates.
Rationale
Actions that help best prepare a child for starting school include the parents speaking about
school as being a positive pleasurable experience, including telling the child of fun activities that
surround school, such as playing. The parents should behave positively and confidently on the
first day of school to help the child have a positive experience. Anticipation of the hard work and
discipline needed for school is premature and does not foster positive thoughts toward school.
Parents should go with their child to their first day of school and introduce the child to the
teacher and facility.

What food item consumed in excess is the cause for most instances of dental caries, obesity, and
metabolic syndrome in a preschooler?
Animal protein
Fruits and vegetables
Sweetened beverages
Milk and dairy products
Rationale
Excess consumption of sweetened beverages and fruit juices may cause dental caries, obesity,
and metabolic syndrome in preschoolers. Animal protein provides the child with the required
amount of protein needed for proper growth of muscles and overall development. Fruits and
vegetables provide the child with dietary fiber. Milk and dairy products provide the child with
calcium, among other nutrients.

What is the normal age by which children can skip on alternating feet, jump rope, and swim?
2 years
3 years
4 years
5 years
Rationale
By the age of 5 years, a normal child acquires the ability to skip on alternating feet, jump rope,
and swim. Two years of age is too early to perform skipping on alternating feet. By 3 years
normal children can ride a tricycle, walk on tiptoe, and balance on one foot for a few seconds. By
the age of 4 years children can skip and hop proficiently on one foot.

What type of play is the most characteristic of preschoolers?

Parallel
Solitary
Telegraphic
Imaginative
Rationale
Preschoolers engage in lots of imitative, imaginative, and dramatic play. Parallel play is
characteristic of toddlers. Solitary play is characteristic of infants. Telegraphic is the term given
to a type of speech in which a child uses three or four words at a time and includes only the most
essential words to convey meaning.

The nurse is assessing the gross motor skills of a 5-year-old child. The nurse finds that the child's
gross motor development is delayed and is closer to that of a 4-year-old child. What activities of
the child lead the nurse to this conclusion? Select all that apply.
The child roller skates with good balance.
The child is able to throw a ball overhead.
The child walks backward with heel to toe.
The child jumps 12 inches and lands on toes.
The child stands on one foot for a few seconds.
Rationale
The ability to throw a ball overhead is developed at age 4. The ability to stand on one foot for a
few seconds is developed by age 3. These findings lead the nurse to conclude that the child has
the gross motor skills of a 4-year-old. The normal gross motor skills attained by the child at the
age of 5 include the ability to roller skate with good balance, to walk backward heel to toe, and
to jump 12 inches high and land on toes. Inability to do these activities would indicate that the
child has not attained the age-appropriate gross motor skills.

The parents of a 4½-year-old girl are worried because she has an imaginary playmate. What is
the appropriate response by the nurse, drawing on knowledge of the preschooler?
A psychosocial evaluation is indicated for this child.
An evaluation of possible parent-child conflict is indicated.
Having imaginary playmates is abnormal after the age of 2 years.
Having imaginary playmates is normal and useful in children of this age.
Rationale
Imaginary playmates are a part of normal development at this age and serve many purposes,
including being a friend in times of loneliness, accomplishing what the preschooler is still
attempting, and experiencing what the preschooler wants to forget or remember. Because an
imaginary playmate is part of normal development, a psychosocial evaluation or evaluation of
the parent-child relationship is not warranted. Imaginary playmates are commonly present during
the preschool years; therefore they are not abnormal after the age of 2 years.

What signs or symptoms would the nurse assess for in a preschooler as characteristics
demonstrating readiness for the next school year? Select all that apply.
Increased memory
Control of bodily systems
Decreased attention span
Use of gestures for mental symbolization
Experience of brief and prolonged periods of separation
Ability to interact cooperatively with other children and adults
Rationale
The next major period in the life of a preschooler is the school years. The preschooler’s
increased memory and attention span, control of bodily systems, experience of brief and
prolonged periods of separation, and the ability to interact cooperatively with other children and
adults are the characteristics that prepare the preschooler for this next major life stage. An
increased attention span and the use of language rather than gestures for mental symbolization
prepare preschoolers for the school years.

The parents tell a nurse that they prefer giving an all-fruit diet to their child to improve overall
health. They have been practicing this for about 6 months. What does the nurse anticipate as
problems or concerns with this diet?
Obesity
Dental caries
Constipation
Hypokalemia
Rationale
Dental caries is a common complication associated with excessive intake of fruits. Delayed
growth, constipation, and obesity are not complications associated with excess fruit intake. Fruits
are a good source of potassium; therefore excess intake of fruits would not cause hypokalemia.
Diarrhea is a complication associated with excess fruit intake. Fruits have less fat content and
can be helpful in prevention of obesity in children.

The nurse is assessing a 4-year-old child. What behavior in the child indicates that the child has
attained socialization capabilities appropriate for this age?
The child is able to eat independently.
The child is well-mannered and is able to sit still.
The child is eager to please adults and do things right.
The child takes pride in the child’s own accomplishments.
Rationale
Socialization is an important task in preschoolers. They take pride in accomplishments and try to
do things to get appreciation. The child learns to be well-behaved by the age of 5 years. A 3-
year-old child can eat independently. The 5-year-old child wants to please adults and therefore
learns to do things right.

According to Erikson, a major task for preschoolers is the development of:

Language
Conscience
Logical thought
Magical thinking
Rationale
According to Erikson, a major task for preschoolers is the development of a conscience.
Development of language, magical thinking, and logical thought are not identified as major tasks
for preschoolers in Erikson's theory of psychosocial development.

With regard to imaginary playmates, what children have a higher tendency to impersonate
characters?
Young girls
Young boys
Older girls
Firstborn child
Rationale
Young boys have a higher tendency to impersonate television characters. Girls and firstborn
children tend to have imaginary companions. Older children develop concrete thinking. They no
longer have imaginary playmates and do not tend to impersonate characters.

What is the earliest age by which children are aware of their gender?
18 months
24 months
30 months
36 months
Rationale
Children are aware of their gender between the ages of 18 months and 30 months. At 24 months
children have a vocabulary of about 300 words. At 30 months children begin to have imaginary
playmates. At 36 months children can ride a tricycle.

The pediatric nurse recognizes that what main transition occurs during Piaget’s preconceptual
phase and the phase of intuitive thought?
The shift from ego to superego
The shift from mistrust to trust
The shift from magical thought to concrete thinking
The shift from totally egocentric thought to social awareness
Rationale
The main transition during the two phases of Piaget’s preconceptual phase, ages 2 to 4, and the
phase of intuitive thought, ages 4 to 7, is the shift from totally egocentric thought to social
awareness. Ego and superego are Freudian concepts, and trust versus mistrust is associated with
Erikson. Preschoolers continue to have magical thinking and do not transition to concrete
thinking until much later.

The nurse is assessing a 3-year-old child and finds that the child has not attained age-appropriate
fine motor skills. What activity shows age-appropriate activity for a 3-year-old?
Tying shoelaces
Drawing a square on a paper
Building a tower with 10 cubes
Using scissors to cut paper in shapes
Rationale
Physical growth and development are rapid in preschoolers. A normal 3-year-old has the fine
motor skills to build a tower of 10 cubes. A 5-year-old may be able to tie shoelaces, copy a
square, and use scissors successfully. A 3-year-old may not be able to do these activities, because
the fine motor skills are not sufficiently developed.

The father of a preschooler has died in an accident, and the mother brings the child for
counseling. The nurse discovers in the child an overwhelming guilt for having wished for the
death of the father, and now the child feels responsible for the cause of the father’s death. What
condition has not been resolved in the child?
Electra complex
Oedipus complex
Instrumental orientation
Punishment and obedience orientation
Rationale
During the preschool years, a particularly stressful thought is wishing a parent to be dead. As a
sense of rivalry and competition develops between the child and the parent of the same sex, the
child wishes death for the parent. This is known as the Oedipus complex for boys and the Electra
complex for girls. This situation is resolved when the child strongly identifies with the same sex
parent. However, if that parent dies before this identification has taken place, then the child
suffers from the guilt of wishing and causing the death. Because the nurse identifies the guilt in
the child after the death of the father, the Oedipus complex must have not been resolved in him.
An unresolved Electra complex would cause the same guilt in a girl with a dead mother.
Instrumental orientation and punishment and obedience orientation are stages of moral
development of a child and are not related directly to the scenario.

A 4-year-old child is playing while the parent is watching television. After some time the child
comes to the parent and says, "Dad! Anna broke the glass." There was nobody else in the house
at that time. What would be the most appropriate response of the parent?
"It is okay. I will tell Anna not to do it again."
"Don't worry; I will get another glass for you."
"Is it? It is really bad; I am going to punish Anna."
"I see only you here, so are you responsible for breaking the glass?"
Rationale
It is normal to have imaginary friends in this age group. Parents should be reassured and should
be encouraged to acknowledge the presence of imaginary friends by giving them a name.
However, they should not allow the child to use this friend to avoid punishment or responsibility.
If this occurs, parents should tell the child that they can see only one person—the child—and that
the child is responsible for cleaning up. Parents should not tell the child it is okay. This may
make the child believe it is acceptable to blame an imaginary friend in the future. Parents should
not tell the child not to worry. The child needs to accept punishment for what the child has done
wrong. Asking the child, "Is it? It is really bad; I am going to punish Anna," does not provide
punishment to the child.
A school nurse observes that a 4-year-old child is hitting another child. The child finds hitting
enjoyable. What rationale is there for the child?
The child is abnormal.
The child is aggressive.
The child is not punished.
The child is being teased.
Rationale
Young children's development of moral judgment is at the most basic level. Children's behavior
depends on the freedom or restrictions placed on their actions. At this age children judge whether
an action is good or bad depending on whether it results in a reward or a punishment. If children
are punished for hitting, they understand that it is a bad thing. If they are not punished, they
consider the action to be good, regardless of the meaning of the act. Hitting another child is not
abnormal or aggressive behavior. The child hits another child because of the inability to
differentiate between good or bad actions and not because the child was teased.

According to Kellogg, what is the importance of a child having uninhibited scribbling and
drawing? Select all that apply.
It assists in learning symbolic language.
It is necessary for children to learn to read.
It assists in development of fine muscle skills.
It assists in development of eye-hand coordination.
It is necessary for children to understand artistic design.
Rationale
According to Kellogg, the importance of a child having uninhibited scribbling and drawing is
that it is necessary for children to learn to read. It also assists in learning symbolic language,
development of fine muscle skills, and development of eye-hand coordination. Kellogg did not
state that it was necessary to help children understand artistic design.

A 4½-year-old boy has been having increasingly frequent angry outbursts in preschool for
approximately 8 to 10 weeks. He is also aggressive toward the other children and teachers. His
parents ask the nurse for advice. What is the appropriate nursing intervention?
Refer the child for counseling with a competent provider.
Explain that this is normal in preschoolers, especially boys.
Encourage the parents to try more consistent and firm discipline.
Talk to the preschool teacher to obtain validation for the behavior the parents report.
Rationale
This is not expected behavior. The child should be referred to a competent professional to deal
with his aggression so an accurate assessment can be made and a care plan formulated. Outward
aggression to others is not normal behavior and should be evaluated. The validation will be
helpful for the referral, but the referral is the priority action. Consistent and firm discipline may
be recommended by the professional once an accurate assessment is made.

When providing the parent with anticipatory guidance, what information might the nurse include
about the differences between the behavior of a 4-year-old and a 5-year-old child?
Four-year-old children need more choices than do 5-year-old children.
Five-year-old children are typically more tranquil than 4-year-old children.
Five-year-old children are typically more aggressive than 4-year-old children.
Five-year-old children have long attention spans and are ready for kindergarten.
Rationale
Five-year-old children are typically more tranquil than 4-year-old children. Although all children
prefer choices, they are especially important to a 3-year-old child, more so than to a 4-year-old
child. Five-year-old children are typically less aggressive than 4-year-old children. There are no
absolute indicators for school readiness. Social maturity and a good attention span are important
criteria for academic readiness but are not always present at age 5.

During assessment the nurse finds that a child lacks fine motor coordination. What games does
the nurse suggest to help the child develop fine motor coordination? Select all that apply.
Puzzles
Skating
Painting
Tricycling
Flash cards
Rationale
After a certain age, children develop fine motor coordination, but some develop more slowly
than others. Games such as painting, puzzles, and flash cards are helpful in improving the fine
motor coordination of the child. Skating and tricycling are helpful for improving muscle strength
of the child.

What emotions does the nurse assess during the naive instrumental orientation stage of
development? Select all that apply.
Fear
Guilt
Justice
Anxiety
Fairness
Rationale
At approximately 4 to 7 years of age, children are in the stage of naive instrumental orientation,
during which a sense of justice and fairness develops. According to Erikson, fear, guilt, and
anxiety develop at the preschooler stage.

The nurse observes that parents pressure the child to speak words that produce sounds beyond
the child's developmental level. What consequences of this parental action does the nurse warn
the parents about? Select all that apply.
Dyslalia
Dysarthria
Motor aphasia
Infantile speech
Sensory aphasia
Rationale
Pressurizing the child to produce words beyond developmental level may be a stressor for the
child. The child tends to respond to the stressor in different ways. The child may develop dyslalia
(articulation problems) and regress to infantile speech. Motor aphasia occurs due to a neurologic
injury such as a stroke. Dysarthria is difficulty with speech that involves the muscles used to
speak. Sensory aphasia is also due to a neurologic injury such as a stroke.

Newly adoptive parents ask the nurse about typical play activities to provide for the 4-year-old
child they are adopting. What answers by the nurse express understanding of usual play activities
of preschool children? Select all that apply.
Dramatic play
Skateboarding
Winter sledding
Associative play
Number flash cards
Rationale
Typical play activities for preschool children include dramatic and associative play, winter
sledding, and use of number flash cards. Skating can be a play activity, but skateboarding is for
older children with more muscle coordination.

What actions or sources of stress in preschoolers are more predominant in 3-year-olds? Select all
that apply.
Name calling
Jealousy of parents’ love
Stuttering or stumbling over words
Stubbornness or uncooperative behavior
Delaying the completion of chores or activities
Rationale
Actions or sources of stress in preschoolers that are more predominant in 3-year-olds include
jealousy of parents’ love, stuttering or stumbling over words, and stubbornness or uncooperative
behavior. Name calling and being upset if they are victims of mockery is most common in 5-
year-olds. Also, procrastination by delaying completion of chores or activities is most common
in 5-year-olds.

What statements are true regarding preschoolers? Select all that apply.
Preschoolers have magical thinking.
Preschoolers have concrete thinking.
Preschoolers do not understand the concept of right and left.
Preschoolers understand time and begin to read clocks if numbers are very large and colorful.
Preschoolers explain a concept as they have heard it described by others, but their understanding
is limited.
Rationale
Correct statements regarding preschoolers include that preschoolers have magical thinking, do
not understand the concept of right and left, and explain a concept as they have heard it described
by others, but their understanding is limited. Preschoolers only understand time in relation to
their own frame of reference, so time is best described in relation to an event. Concrete thinking
is not developed until school age.
What are typical speech communication patterns for normal developing 3- to 4-year-old
children? Select all that apply.
Using telegraphic speech
Asking only essential questions
Imitating new words proficiently
Talking incessantly, whether or not anyone is listening
Including only a few words in sentences most essential to convey meaning
Rationale
Typical speech communication patterns for normal developing 3- to 4-year old children include
use of telegraphic speech in which they include only three to four most essential words to convey
meaning. They also talk incessantly, whether or not anyone is listening; 3- to 4-year-old children
also are able to imitate new words proficiently. They generally ask many questions.

The nurse is assessing a 4-year-old child. What age-appropriate language skills would the nurse
expect in this child? Select all that apply.
The child at this age has a vocabulary of 1500 words.
The child at this age has a vocabulary of 2100 words.
The child can follow three commands in succession.
The child uses complete sentences of three to four words.
The child forms a proper sentence with six to eight words.
Rationale
A nurse should be aware of the normal age-appropriate developmental skills including language
skills. A 4-year-old child should have a vocabulary of 1500 words and should be able to
complete sentences of three to four words. A child of 5 years has a vocabulary of 2100 words,
can follow three commands in succession, and can use sentences of six to eight words with all
parts of speech.

On assessment the nurse learns that a child can use all parts of speech correctly except when
words do not follow traditional grammatical rules. What is the approximate age of the child?
3 years
4 years
5 years
6 years
Rationale
By the age of 6 years, a child can use all parts of speech correctly except for deviations from the
rule. Children who are 3 years old ask many questions and use plurals, correct pronouns, and the
past tense of verbs. Four-year-old children can form sentences of about four words and include
more words to convey meaning. Five-year-old children use longer sentences of four to five
words and use more adjectives and verbs to convey messages.

When the parent tells the preschooler to put on shoes, the preschooler wears the left shoe on the
right foot and the right shoe on the left foot. What does this action indicate?
The child is hyperactive.
Expected behavior at this age.
The child has a mental illness.
The child is slow to learn and grasp skills.
Rationale
Preschoolers do not understand the concept of left and right. They may use concepts correctly
but only in circumstances in which they have learned them. They may know how to put on the
shoes by remembering that the buckle is always on the outside of the foot. However, if asked to
wear a shoe without a buckle, the child may get confused as to which shoe fits which foot. This
activity does not indicate that the child is hyperactive, a slow learner, or has a mental illness.

Chapter 15
The nurse is performing an assessment of a 9-year-old child. The nurse finds that the child's
mother is very concerned about the child's appearance because the child is very thin. What is the
appropriate response by the nurse?
"Because your child is thin, you need to provide more fatty foods in the child's diet."
"Encourage your child to play indoor games so that too much exercise won't lead to additional
weight loss."
"Don't worry, many children are underweight during this age, and this problem corrects itself as
they become better eaters."
"The child looks thinner now because of the reduction and redistribution of fat throughout the
body. This is normal."
Rationale
School children may look thinner than they did as toddlers and preschoolers because of the
reduction of fat and its redistribution to different parts of the body. During these years, the "baby
fat" gradually diminishes, giving the children a slimmer appearance. This apparent loss of weight
is not necessarily due to poor eating, so the nurse should not give false assurances of this type.
The nurse should advise the mother to feed the child a diet that is high in calories and rich in
protein but to avoid fatty foods that can eventually lead to childhood obesity. High-calorie and
high-protein foods are preferred because they promote proper growth and development. The
child must be encouraged to play both indoor and outdoor games. Physical activity helps in
skeletal lengthening and fat diminution.

The parents of a 13-year-old child often work until late at night and are not able to be home
when the child returns from school. What action employed by the parent is appropriate?
The parents set the water heater to 69.9°C for faster heating.
The parents instruct the child to heat food in the microwave at low heat.
The parents advise the child to play on the trampoline if the child is bored.
The parents advise the child to take aspirin if the child has fever.
Rationale
The parents should follow safety guidelines and instruct the child to follow them to prevent
accidents. Children in middle childhood exhibit explorative behavior and often tend to do
experiments. The parents should give repeated instructions and teach safety guidelines. The
parents should teach the child to use the microwave at low heat to prevent burns. The parents
should set the water heater to 48.9°C to avoid scald burns. Trampoline injuries can be very
serious, and the child should be allowed to play on it only under adult supervision. Medicines,
including aspirin, should be taken only with adult supervision.
A mother shouts at her 7-year-old child for doing wrong. Two days after this incident, the child
develops fever. The child believes that fever is a punishment by God. How does the nurse
interpret the child’s response?
The child may require spiritual healing.
The child has a psychologic disorder.
The child is suffering from depression.
It is a normal behavior seen at this age.
Rationale
At this age, children are fascinated by the concepts of God, hell, and heaven. They show concrete
thinking at this age, and abstract thoughts like those of spirituality and God are difficult for them
to understand. Children believe that God will punish them for misbehavior. Fever as a disease
manifestation is not associated with spiritual beliefs, psychologic disorders, or depression.

A parent tells the nurse that her 8-year-old child throws a fit each night, refusing to go to bed.
What interventions can the nurse suggest to the mother to help promote sleep in the school-age
child?
Forcing the child to take a nap after school
Encouraging a quiet activity before bedtime
Having the child watch a movie before bedtime
Moving up the bedtime to encourage more sleep
Rationale
A quiet activity such as coloring, reading, or listening to music before bed can help facilitate the
process of going to bed. Many school-age children do not feel tired and therefore resist bedtime.
Forcing the child to take a nap after school is not appropriate because children at this age no
longer require naps. Having the child watch a movie before bedtime is not an effective way to
promote sleep; watching TV or being in front of a screen has been shown to interfere with sleep.
Setting back the bedtime, rather than moving it up, as the child gets older is a better way to
promote sleep in the school-age child.

What are some of the ways in which play helps school-age children develop?
They learn to not experience guilt when they misbehave.
They learn that misfortunes are punishment for misdeeds.
They acquire mastery over themselves, their environment, and others.
They begin to understand the rules and behaviors of social interaction and the reasons behind
them.
Rationale
Play helps school-age children develop by teaching them to acquire mastery over themselves,
their environment, and others. Play does not teach children to not experience guilt when they
misbehave. Play does not teach children that misfortunes are punishment for misdeeds. Although
school-age children can understand the rules and behaviors of social interaction, play does not
help them understand the reasons behind them.

During middle childhood, some children tend to tell stories to their parents by exaggerating
events at school. What suggestion does the nurse provide parents to manage this behavior?
Inform the child's teacher immediately.
Consult a child psychiatrist immediately.
Check with the peers and playmates of the child.
Teach the difference between reality and fantasy.
Rationale
During middle childhood, children tend to tell stories and often exaggerate the events that take
place in school. They tell these stories to impress their friends and family. However, most
children are able to distinguish between fantasy and reality, but some may not acknowledge the
difference. The nurse should suggest that parents teach them the difference between reality and
fantasy. Telling stories to the parents and peers in an exaggerated way is a normal behavior in
school-age children. Therefore it does not indicate that the child has mental illness, and the child
need not be referred to a psychiatrist. The parents should not encourage the child by listening to
the child's stories. The child may get confused or feel rejected if parents complain to the teacher.
Checking with the peers and playmates of the child may not stop the child from telling imaginary
stories.

What has the most significant impact on the socialization of school-age children?
Parents
Teachers
Classmates
The child's self-concept
Rationale
Classmates have a significant impact on the socialization of children. Teachers and parents are
important, but classmates have the most significant impact on the socialization of school-age
children; peer relationships become increasingly important as the child grows older. The school-
age child's self-concept is important but does not have the most significant impact on
socialization.

The school nurse is asked to speak with the parents of a 10-year-old boy who has been bullying
other children. What is the knowledge basis the nurse would use for this interaction?
Bullying at this age is considered normal.
Children who bully others usually join gangs.
Bullying often manifests itself in children who witness violence or abuse at home.
Bullying is a short-term problem that is generally outgrown by the end of the school-age years.
Rationale
Bullying often manifests in children who may witness violence or abuse at home. Children who
bully may also come from homes with low parental involvement. Bullying is a maladaptive
response to poor relationships with peers and lack of group identification; therefore, it is not
considered normal behavior. Children who chronically bully tend to be impulsive, easily
frustrated, and at increased risk for dropping out of school, but there is no direct correlation
between bullying and joining a gang. Children who bully may be at risk for long-term
psychological disturbances and psychiatric symptoms. Future problems for bullies may include
violence, substance abuse, and criminal convictions, which often occur in adulthood.

The nurse recognizes that bullying is a common occurrence during the school-age years. How
are the victims of bullies affected? Select all that apply.
Nightmares
Social isolation
Increased self-esteem
Psychologic distress
Increased self-harm behaviors
Rationale
Bullying can cause victims to suffer psychologic distress, increased self-harm behaviors, social
isolation, nightmares, depression, anxiety, worry, sadness, and violent behaviors. Increased self-
esteem is not correlated with being a victim of a bully.

Although puberty can begin in either gender after the age of 8 years, at what age does puberty
generally begin for girls and boys?
8 years for girls, 10 years for boys
9 years for girls, 11 years for boys
12 years for girls, 10 years for boys
10 years for girls, 12 years for boys
Rationale
Puberty generally begins in girls at 10 years of age and at 12 years of age in boys.

What is the most effective means of preventing dental caries in school-age children?
Flossing the teeth at least three times per week
Unsupervised brushing of teeth before bedtime
Regular consumption of fluorinated drinking water
Brushing teeth after meals, after snacks, and at bedtime
Rationale
Brushing teeth after meals and snacks and at bedtime is the most effective means of preventing
dental caries in school-age children. Teeth need to be flossed, after brushing, two or three times a
day, not three times per week. Unsupervised brushing of teeth before bedtime is not effective in
preventing dental caries in school-age children. Regular consumption of fluorinated drinking
water is not the most effective means of preventing dental caries in school-age children.

During assessment, the nurse observes that the child's new secondary teeth are appearing too
large for the face. What is the stage of child development for this child?
Inferiority stage
Ugly duckling stage
Prepubescence stage
Accomplishment stage
Rationale
The child is in the ugly duckling stage. In this stage, the teeth appear too large for the face. Facial
appearance also changes, making the child's face appear disproportionate. A sense of inferiority
is related to the accomplishment stage of Erikson's psychosocial development theory.
Prepubescence, which lasts approximately 2 years, begins at the end of middle childhood and
ends with the 13th birthday. Accomplishment is one of the stages of Erikson's psychosocial
development theory.

According to Freud, middle childhood is associated with an increase in relationships with which
children?
Older children
Same-sex peers
Younger children
Opposite-sex peers
Rationale
According to Freud, middle childhood is associated with an increase in relationships with same-
sex peers. The incidence of opposite-sex peer relationships increases during the adolescent years.
Relationships with younger children are not common during middle childhood, nor are
relationships with older children.

The nurse manager instructs a nurse to conduct a group activity for assessing physical and
cognitive development in 6- to 12-year-old children. What suggestion given by the nurse
manager is appropriate?
"Give grades and material rewards to the children after performing the task."
"Compare the performance of one child with the other children based on grades."
"Do not allow the children to interact with each other while doing the task."
"A child who performs well in all the tasks can be considered as mentally fit."
Rationale
Children 6 to 12 years of age are eager to participate and effectively complete the given tasks.
The nurse can conduct group activities to assess the physical and mental abilities of the children,
because they are motivated in the presence of peers and effectively participate in the task. The
nurse should adopt the reward system, such as giving grades and material rewards to encourage
the children. In order to avoid having children feel inferior, the nurse should not compare them
with their peers. The children must be encouraged to interact with their peers and help each other
in order to develop the ability to cooperate and to compete with other children effectively. No
one has the ability to do everything perfectly, so children should not be expected to perform well
in all tasks.

What is a source of stress for both 7-year-olds and 9-year-olds?

Moodiness
Interruptions
Rebelliousness
Aversion to the opposite sex
Rationale
Interruptions are a source of stress for both 7-year-old and 9-year-old children. The 7-year-old
hates to be disturbed when intensely involved in an activity. The 9-year-old continues to dislike
interruptions; however, the 9-year-old will usually resume an activity after an interruption.
Moodiness is a source of stress for the 7-year-old; this child is often moody, unhappy, or
pensive. This is not a particular problem faced by 9-year-olds. Rebelliousness is a source of
stress for the 9-year-old; this child occasionally tests independence by rebelling. A 7-year-old
child has not yet started to rebel. Aversion to the opposite sex is a source of stress in the 9-year-
old who prefers to engage in sex-segregated play. A 7-year-old starts to become more selective
about playmates; however, aversion to the opposite sex is not specifically observed in children of
this age.

What is an important consideration in the prevention of injuries during middle childhood?

Most injuries occur in or near school or home.
Peer pressure is not strong enough to affect risk-taking behavior.
Injuries from burns are the highest at this age because of fascination with fire.
Lack of muscle coordination and control results in an increased incidence of injuries.
Rationale
Most children in the middle years spend the majority of their time in and around school or home;
therefore the risk for injuries is increased in and around these areas. Peer pressure as an impetus
for risk-taking behavior begins in the school-age years but is more significant in adolescence.
Burn injuries are higher in the toddler years, when children are curious and mobile. They may
expose themselves to objects capable of burning them (e.g., hot pots of water in the kitchen).
Automobile accidents, with children as pedestrians or passengers, account for the majority of
severe accidents in the middle years. School-age children have more refined muscle
development, which results in an overall decrease in the number of accidents. Lack of muscle
coordination and control leading to injuries occurs in younger children.

While performing assessments of students at a grade school, the nurse learns that some are
latchkey children. What characteristics occur in latchkey children?
The children have many friends.
The children are brave and free from illness.
The children spend most of their time at home.
The children are frequently supervised by adults.
Rationale
Children in elementary school who are left to care for themselves before or after school without
supervision of an adult are referred to as latchkey children. Such children may lack proper care.
They spend most of their time at home and do not spend time outside or doing physical activities.
These children are fearful and have chronic illnesses due to lack of care and physical activities.
These children have fewer friends, because they are not able to interact with peers. Such children
have to spend time alone before and after school and lack supervision by adults and parents.

A student nurse is comparing the sources of stress for 6-year-old children and 12-year-old
children. What source of stress is prevalent in both of these age groups?
Health
Aggression
Competition
Peer pressure
Rationale
Competition is a source of stress for both 6-year-old and 12-year-old children. The 6-year-old
wants to be "first" or best, while the 12-year-old still continues to be highly competitive and
looks to peer group for prestige. Health is a source of concern for the 12-year-old, who may
become a hypochondriac during this period of development. This is not a point of concern for 6-
year-old children. Aggression is a particular source of stress for 6-year-olds; temper tantrums
peak at this age, and the child may become hostile or aggressive. Aggression is not a particular
problem for 12-year-olds. Peer pressure is a powerful motivating force and a major source of
stress for the 12-year-old child; however, this is not a concern felt by 6-year-olds.

A nurse working with school-age children is aware of physical maturation. What information is
accurate and knowledge is important for a nurse working with school-age children?
Bladder capacity is greater in boys than in girls.
The immune system becomes less competent in its ability to localize infections.
Bones cease to ossify and yield to pressure, and muscle tissue pulls more readily.
The heart grows more slowly during the middle years and is smaller in relation to the rest of the
body.
Rationale
The heart grows more slowly during the middle years and is smaller in relation to the rest of the
body. Bladder capacity is greater in girls than in boys. The immune system is not less but more
competent in its ability to localize infections. Bones continue to ossify throughout childhood but
yield to pressure, and muscle pulls more readily than with mature bones.

A 6-year-old child's parent tells the nurse that the child has a loose tooth. The parents are
concerned about the child having a loose tooth. What is the appropriate response by the nurse?
"The child has a chronic disease."
"It is a normal finding at this age."
"The child has calcium deficiency."
"It occurs due to vitamin A deficiency."
Rationale
At the middle childhood stage, the process of shedding deciduous teeth begins. The nurse tells
the child's parent that a loose tooth is a normal finding at this age. It does not indicate that the
child has chronic disease, calcium deficiency, or vitamin A deficiency. Calcium deficiency
affects the bones and does not cause tooth shedding. Vitamin A deficiency does not affect teeth
or cause tooth loss.

The nurse is caring for a child with a history of recurrent diarrhea and no identified physical
cause for the diarrhea. The nurse believes the child to have diarrhea secondary to stress. What
signs and symptoms of stress does the nurse anticipate assessing in this child? Select all that
apply.
Pyrexia
Headache
Bedwetting
Chronic illness
Disturbed sleep patterns
Rationale
While caring for children, a nurse should look for signs and symptoms of excessive stress. The
nurse should further explore the feelings of the patient if there are symptoms such as headache,
bedwetting, and disturbed sleep patterns. Chronic illness is not a symptom of stress. Pyrexia is
not a symptom of stress but can be seen in other conditions such as diarrhea.

After interacting with the parents of a 10-year-old child, the nurse understands that they are
effectively following guidelines to help their child with school work and grades. What statement
made by the parents supports the conclusion of the nurse?
"We have arranged home tutoring sessions for our child twice a day."
"We are strict and allow our child to watch television only on achieving good grades."
"We discuss all our concerns with the teacher at the annual parent-teacher conference."
"We help our child with homework by explaining the questions and avoid giving answers."
Rationale
The parents should help the child complete homework by explaining the concepts
and encouraging them to find the answers. If the parents give answers, the child may not read the
complete material and will not gain complete knowledge. Parents should communicate with the
child's teachers regularly instead of meeting once during an annual conference. The child may
feel stressed due to excessive sessions of tutoring. The parents should arrange tutoring sessions
only when they are recommended by the child's teachers. Parents should encourage the child to
focus on studies rather than on grades. The child may feel stressed if strict rules are imposed for
not getting good grades.

A nurse is providing general guidelines and teaching to a group of parents of 10-year-old

children on how to best help their children in school. What statement made by a parent indicates
effective learning?
"I should encourage my child to ask questions."
"I should immediately point out whenever my child makes a mistake."
"I must encourage my child to focus on schoolwork, because too many hobbies can be
overwhelming."
"I must arrange for activities that occupy the whole of my child’s free time so that my child does
not get bored."
Rationale
Parents should encourage their child to ask questions so that the child can discover sources for
information or places to explore and investigate. The parents should not be quick to chastise
children for their mistakes; children should be encouraged to try out new solutions to problems
without the fear of making mistakes, because this stimulates creative thinking and problem
solving. While pursuing too many hobbies can definitely be stressful for the child, the parents
must also foster the development of hobbies and collections by their children and not just make
them focus on schoolwork. Parents should encourage their children to wonder and reflect during
free time.

What would the nurse teach the parent of a child, who is home alone after school, regarding
telephone use? Select all that apply.
Teach the child the parent’s name.
Ensure that the child knows how to report emergencies.
Teach the child the home address so that the child can inform anyone who calls.
Teach the child to say that the parents are not at home and the caller should call back later.
Instruct the child to tell the caller that the parents cannot come to the phone right now and will
call back later.
Rationale
A latchkey child is the term used to describe children in elementary school who are left to care
for themselves before or after school without supervision of an adult. A nurse who is caring for
such a child would instruct the parent to teach the child the home telephone number, address, and
parent’s name. This information would come in handy if the child ever has to report an
emergency situation through a phone call. The parent should ensure that the child knows how to
report emergencies and that there is a list of emergency numbers by the telephone. The parent
should also instruct the child not to tell a caller that parents are not at home; instead, the child
should be taught to say that the parents cannot come to the phone right now and will call back
later. While the child needs to be taught the home address, this is to inform an emergency contact
person if necessary, but not to inform casual callers. The parent needs to instruct the child never
to tell casual callers that the parents are not home.

Parents of a school-age child tell the nurse that their child is being consistently bullied at school.
What is appropriate information for the nurse to provide the parents to help the child?
Call the police.
Instruct the child in how to handle the situation.
Discipline the child for being the victim of a bully.
Communicate concerns to the teacher and principal.
Rationale
When a child is being bullied, it is essential that the parents communicate their concerns with the
teacher and principal at the school in order to come up with a solution to the problem. Calling the
police may not be necessary in all cases, but school officials need to be informed in every case.
Instructing the child in how to handle the situation is a good intervention, but consistent bullying
at school needs to be reported to the teacher and principal. Disciplining the child is not an
appropriate method of addressing bullying.

The parents of an 8-year-old girl tell the nurse that their daughter wants to join a soccer team.
What is the appropriate recommendation, based in the nurse's knowledge of this age group?
Organized sports, such as soccer, are not appropriate at this age.
Competition is detrimental to the establishment of a positive self-image.
Sports participation is encouraged if the sport is appropriate to the child's abilities.
Girls should compete only against girls because at this age boys are larger and have more muscle
mass.
Rationale
The parents should help the child select a sport that is suitable to her capabilities and interests.
Team sports contribute to the school-age child's social, intellectual, and skill growth. Organized
sports for school-age children can provide safe, appropriate activities with supportive parents and
coaches. The desire to participate in competitive team sports develops from a need for peer
interaction for the school-age child. A sport that meets the child's capabilities and interests
should be selected. The physical changes in boys described take place during puberty, later in the
school-age years; there is therefore no reason for boys and girls to compete separately at the age
of 8 years.

What is one cognitive task that a school-age child is working to master?

Conservation
Intuitive reasoning
Object permanence
Transductive reasoning
Rationale
Piaget describes the cognitive developmental task of children between 7 and 11 years as
mastering the concept of conservation. Intuitive reasoning occurs in the preoperational stage,
from 2 to 7 years of age. Object permanence occurs in the sensorimotor stage, between birth and
2 years. Transductive reasoning occurs in the preoperational stage, between 2 and 7 years.
The parent of a 6-year-old child is worried because the child frequently suffers from diarrhea and
stomach upset. What is an accurate statement for the nurse to respond to the parent?
"Children at age 6 eat less due to reduced appetite."
"The immune system in 6-year-old children is not well developed."
"The digestive system in 6-year-old children is not well developed."
"Children tend to acquire infections during the first two years of schooling."
Rationale
During early middle childhood, children are more prone to infections as they start going to
school and are exposed to other children who may have infections. The immune system is well
developed, and 6-year-old children are able to combat localized infections. The digestive system
is well developed, so there are fewer stomach upsets. Six-year-old children begin eating more as
their appetites increase.

The parents of a 7-year-old boy tell the nurse that their son wants to join a baseball team. What
guidelines about sports at this age would the nurse include when responding to the parents'
statement?
Organized sports, such as baseball, are not appropriate at this age.
Competition is detrimental to the establishment of a positive self-image.
Sports participation is encouraged if the sport is appropriate to the child's abilities.
Boys should compete only against other boys because at this age they are larger than girls.
Rationale
Sports participation should be encouraged if the sport is appropriate to the child's abilities and
physical and emotional development. Organized sports can be beneficial for school-age children.
School-age children enjoy competition. With appropriate guidelines, children can be taught the
proper techniques and safety measures to avoid injuries. Before puberty there is no essential
difference in strength and size between boys and girls.

A group of boys has formed a club that is open to other boys who like to play sports. What is this
behavior considered?
Bullying
Promoting gang violence
Promoting isolation and exclusion
Normal social development of school-age children
Rationale
One of the outstanding characteristics of middle childhood is the creation of formalized
groups or clubs. Peer-group identification and association are essential to a child's socialization.
Poor relationships with peers and a lack of group identification can contribute to bullying. Poor
relationships with peers can promote gang violence and isolation or exclusion.

A father is concerned that his school-age child has started to lie on occasion. What information
would the nurse provide to the parent in this situation?
Be particular about remaining truthful in your relationship with your child.
Do not worry because your child cannot yet distinguish between fantasy and reality.
Resort to corporal punishment so that the dishonest behavior is rooted out at an early stage.
Confront your child about the offensive behavior because it is normal in young children.
Rationale
The nurse should help the father understand the importance of his own behavior as a role model
and of being truthful in his relationship with his child. While parents can be reassured that all
children lie sometimes, they can discuss the issue with the children directly to impress on them
how much of their own security and respect is lost when they are not believed. Preschool
children often have difficulty distinguishing between fact and fantasy; they often lie, even though
they do not have the cognitive capacity to deliberately mislead. School-age children still continue
this behavior, but they can distinguish between what is real and what is make-believe. Corporal
punishment should not be used, because it is of limited value and is associated with increasingly
disruptive behavior in children.

Parents are asking for information on ways to assist their 10-year-old child with school. What
information would the nurse include when giving parents guidelines about helping their children
in the school-age years?
Punish children who fail to perform adequately.
Help children as much as possible with their homework.
Accept responsibility for children's successes and failures.
Communicate with teachers if there appears to be a problem.
Rationale
Parents should communicate with teachers if there is a problem and not wait for a scheduled
conference. Parental involvement is one factor in a child's success in school. Children need to do
their own homework; this cultivates responsibility. Discipline should be used to help children
control behaviors that might be affecting school performance, but failure to perform adequately
should not be punished itself. Communicating with the child is a better solution to getting to the
root of the school performance problem. School-age children need to develop responsibility;
keeping promises and meeting deadlines lays a successful foundation for adulthood and adult
responsibilities.

A nurse discusses the maturation of systems in a school-age child with student nurses. What
statement made by a student nurses indicates effective learning?
"The heart grows faster in the school-age child than at any other period of life."
"The school-age child can have several infections in the first 1 to 2 years of school."
"Physical maturity in the school-age child correlates with emotional and social maturity."
"The school-age child needs to be fed more carefully, promptly, and frequently than a
preschooler."
Rationale
School-age children can have several infections in the first 1 to 2 years of school because of
increased exposure to others in school classes while immunity develops. The heart grows more
slowly during the middle years and is smaller in relation to the rest of the body than at any other
period of life. Physical maturity in the school-age child is not necessarily correlated with
emotional and social maturity. Children will generally have the emotional and social maturity
that corresponds to their age. Because the gastrointestinal system in a school-age child is more
mature than that in a preschooler, the school-age child does not need to be fed as carefully, as
promptly, or as frequently as before.

The parents of a 10-year-old child reveal to the nurse that after watching the news of a child-
kidnapping case, their child is experiencing nightmares and bedwetting. The child has also
stopped going out to play due to the fear of being kidnapped. What priority intervention does
the nurse employ for the child?
Teach relaxation techniques to the child.
Encourage the child to play outdoor games.
Explain the reason for nightmares to the child.
Suggest parents wake the child up at night to use the restroom.
Rationale
The increase in violence and rapid spread of information through media may cause stress in the
child. Nightmares and bedwetting are indications of stress. The immediate nursing intervention is
to teach relaxation techniques to the child. The child needs physical activity, so the nurse should
encourage the child to play outdoor games under the parent's supervision. Explaining the reasons
for nightmares and bedwetting should be postponed until the child is free from immediate stress.
The nurse should not suggest waking the child at this time. Work on removing the fear and stress
of kidnapping.

What behavior is characteristic of the concrete operations stage of cognitive development?

Inability to put oneself in another's place
Progression from reflex to imitative behavior
Increasingly logical and coherent thought processes
Ability to think in abstract terms and draw logical conclusions
Rationale
Increasingly logical and coherent thought processes are characteristic of concrete operations.
Children in this stage are able to classify objects. Progression from reflex activity to imitative
behavior is characteristic of the sensorimotor stage, which spans the period from birth to 2 years
of age. Inability to put oneself in another's place is characteristic of the preoperational stage, ages
2 to 7 years. Adolescents, in the formal operations stage, have the ability to think in abstract
terms and draw logical conclusions.

During the home visit, the parents of a 10-year-old child ask the nurse about safety guidelines
because the child wants a bicycle. What statement by the parents indicates the nurse's teaching
has been effective?
"Replace your helmet every 10 years."
"Give hand signals just before turning the bicycle."
"Wear light-colored clothes while riding the bicycle at night."
"Carry heavy objects at the back of the bicycle instead of the front."
Rationale
The nurse teaches bicycle safety guidelines to the child to prevent injuries due to accidents. The
child should be instructed to wear light-colored clothes and attach a florescent cloth to the
bicycle at night to increase visibility and prevent accidents. The child should be instructed to buy
properly fitted helmets that are approved by the Consumer Product Safety Commission. The
helmets should be replaced every 5 years or sooner as recommended by the manufacturer. Old
helmets may not protect from head injuries. The child should be instructed not to carry heavy
objects either on front or back of the bicycle, because the child may not be able to balance and
can fall. Hand signals should be given well in advance so that others can regulate their speed and
change their direction.
What is a common characteristic of the psychosocial development of school-age children?
A developing sense of initiative is important.
Peer approval has not yet become a motivating factor.
Motivation comes from extrinsic rather than intrinsic sources.
Feelings of inferiority or lack of worth can be derived from children themselves or from the
environment.
Rationale
The school-age child is eager to develop skills and participate in activities. All children are not
able to do all tasks well, and the child must be prepared to accept some feelings of inferiority, as
highlighted in Erikson's stage for this age group of industry versus inferiority. Initiative versus
guilt is the stage characteristic of preschoolers. Peer group formation is one of the major
characteristics of school-age children. School-age children gain satisfaction from independent
behaviors that are internally driven and accomplished.

A nurse is teaching student nurses about the cognitive milestones reached by children at different
stages of development. What statement made by a student nurse indicates effective learning?
"A 7-year-old child can use the telephone for practical purposes."
"An 8-year-old child reads for practical information or own enjoyment."
"A 6-year-old child understands concepts of space and cause and effect."
"An 11-year-old child can write occasional short letters to friends on self-initiative."
Rationale
An 11-year-old child can write occasional short letters to friends or relatives on self-initiative.
This statement made by the nurse indicates effective learning. Children in the age group of 10 to
12 years can use the telephone for practical purposes; a 7-year-old usually cannot do so. Children
in the age group of 10 to 12 years read stories or library books for practical information or
enjoyment; an 8-year-old usually cannot do so. Children in the age group of 8 to 9 years
understand the concepts of space, cause and effect, nesting puzzles, and conservation, that is,
permanence of mass and volume; a 6-year-old usually does not.

A child presents with symptoms of nightmares, depression, and anxiety. While speaking with the
child, the nurse finds that the child has a fatalistic orientation to the future. What is
the most common reason for this child’s assessment findings?
Conflict with friends
Perceived lack of love
Exposure to repeated violence in the family
Inability to distinguish between fact and fantasy
Rationale
The symptoms of nightmares, depression, and anxiety, along with a fatalistic orientation toward
the future, can indicate that the child is suffering from posttraumatic stress disorder. Children
exposed to repeated violence can display hyperarousal symptoms leading to posttraumatic stress
disorder. Conflict with friends can be a source of stress for the child, but this is not likely to lead
to posttraumatic stress disorder. Perceived lack of love can lead to antisocial behaviors in school-
age children, and children can steal to make up for this perceived lack. However, symptoms of
nightmares, depression, and anxiety are not specifically related to perceived lack of love.
Inability to distinguish between fact and fantasy is common in preschoolers and leads children to
lie. This is not related to posttraumatic stress disorder.
The school nurse is discussing dental health with a class of first grade children. What teaching
would be included by the nurse?
Teaching how to floss teeth properly
Recommending nonfluoridated toothpaste
Emphasizing the importance of brushing before bedtime
Recommending a toothbrush with hard nylon bristles to get between the teeth
Rationale
Children should be taught to brush their teeth after meals and snacks and before bedtime to
prevent dental caries. The American Dental Association recommends fluoridated toothpaste for
this age group. Parents should help with flossing until children develop the dexterity required,
when they are in about the third grade. A toothbrush with soft nylon bristles is recommended to
prevent damage to the gums.

The nurse is completing physical assessments on school-age children. What is a physical change
the nurse would anticipate noting on physical exam for these children?
The cranium grows faster than the face in school-age children.
There is no correlation between the physical indicators of maturity and success in school.
The increase in head circumference with respect to standing height indicates increased maturity.
The strength of school-age children is less than what the increase in their muscles would warrant.
Rationale
The school-age child has an increase in the percentage of body weight represented by muscle
tissue. By the end of this age period, both boys and girls have doubled their strength and physical
capabilities. This increased strength is often misleading, because the muscles are still
functionally immature when compared with those of the adolescent, and they are more readily
injured by overuse. Facial proportions change in the school-age child, because the face grows
faster in relation to the remainder of the cranium; in fact, the skull and brain grow very slowly
during this period. The physical indicators of maturity seem to correlate with success in school.
The decrease in head circumference with respect to standing height in a school-age child is one
of the most pronounced changes that seems to best indicate increasing maturity.

A student nurse compares the sources of stress for both 6-year-olds and 10-year-olds. What
source of stress is prevalent in only one of these age groups?
Stature
Teasing
Shyness
Competition
Rationale
Stature is a source of stress only in 10-year-olds. Both boys and girls at this stage may be upset
by the fact that the girls are taller, and the extremely small or extremely large child may be
concerned about personal size. Stature is not a source of stress for 6-year-olds, when there is not
much difference in height between boys and girls. Teasing is a source of stress for both these age
groups. A 6-year-old engages in teasing but becomes upset when on the receiving end. A 10-
year-old also engages in teasing, scapegoating, or vicious attacks to temporarily boost self-
image, even though there is a sense of guilt felt afterward. Shyness is a source of stress for both
these age groups. A 6-year-old may initially be shy in a new situation but usually recovers
quickly; an already existing shyness problem in a 10-year-old is likely to become more
pronounced at this age. A 6-year-old wants to be the "first" or best; a 10-year-old continues to be
highly competitive and looks to peer group for prestige.

What statement is true regarding peer groups formed by children during the early school years?
"The groups are loosely organized and have little formal structure."
"The groups are composed predominantly of children of the same sex."
"The groups can contribute to bullying when there is excessive peer identification."
"The groups invite membership from children who are secure enough to function independently."
Rationale
During the early school years, groups are small and loosely organized, with changing
membership and little formal structure. Groups formed in the later school years are composed
predominantly of children of the same sex. In the earlier school years, there may be a mixture of
both sexes in a group. Poor relationships with peers and a lack of group identification can
contribute to bullying behavior. Excessive identification with the peers in a group does not do so.
Children in a peer group merge their identities with the identities of their peers. They substitute
conformity to a peer-group pattern for conformity to a family pattern while they are still too
insecure to function independently.

A nurse is discussing anticipatory socialization in children ready to go to school for the first time
with parents of preschool-age children. What information will the nurse include to educate the
parents?
Children going to school for the first time do not have a realistic concept of what school
involves.
Clinging behavior by parents negatively affects the child’s ability to adjust to the school
environment.
Early childhood programming that stresses social aspects is particularly effective in facilitating
later academic achievement.
Middle-class children have to make a lot of adjustment, because the values reflected in school
are far from what they are used to at home.
Rationale
Some parents may express their unconscious attempts to delay their child’s maturity by clinging
behavior, particularly with their youngest child. This behavior in the parents negatively affects
the child’s ability to adjust in the school environment. Most children have a fairly realistic
concept of what school involves by the time they enter school. This is facilitated by the
information they receive regarding the role of the pupil from the parents, playmates, and the
media, as well as their experience in daycare or preschool and kindergarten. Early childhood
programming that stresses cognitive more than social aspects appears to be more effective in
facilitating later academic achievement. Schools tend to reflect dominant middle-class customs
and values; therefore, middle-class children have fewer adjustments to make and less to learn
about expected behavior.

A nurse is providing specific guidelines to parents for helping their children who are starting
school this year. What information will the nurse include?
"Accept the separation readily as your child starts attending school for the first time."
"Express openly in front of the child that school has a different culture from home that you have
little power to affect."
"Remember that viewing television makes it difficult for the child to adjust by giving an
unrealistic picture of what to expect in school."
"Realize that a preschool program that focuses on developing social aspects is more effective in
facilitating later academic achievement."
Rationale
Successful adjustment of a child is directly related with the parents’ readiness to accept the
separation associated with school entrance. Clinging behavior demonstrated by the parents might
be unconscious attempts to delay the child’s maturity. Parents who view the school as an alien
culture and one that they have little, if any, power to affect may unknowingly teach their children
to be fearful and resentful toward it. This can occur even though the parents agree with school’s
purposes and objectives. It is more effective for parents to view school as a place that they have
helped to create and support. Children receive information regarding the role of pupils in school
from different sources, including the media, before they even start school. Television influences
the acquisition of information and attitudes and provides anticipatory socialization to the
children. It has been found that later academic achievement is facilitated by childhood
programming that stresses cognitive development more than social aspects.

A nurse preceptor is working with a new school nurse. The preceptor is discussing cognitive
development in middle childhood. What statement made by the new nurse indicates effective
teaching?
"During middle childhood, children cannot memorize symbols."
"During middle childhood, children have a rigid and egocentric view."
"During middle childhood, children learn from their past experiences."
"During middle childhood, children have very low perceptual thinking."
Rationale
During middle childhood, children learn from their experiences. They use behaviors adopted in
the past to evaluate and interpret present situations. Children age 6 to 12 years (middle
childhood) lose the rigid and egocentric view of preschoolers and begin to develop empathy and
to perceive the situation from the other's point of view. During middle childhood, children can
memorize symbols and develop problem-solving abilities. They also begin making judgments on
what they see and gradually develop perceptual thinking.

A nurse is teaching a group of parents about the growth and developmental stages in school-age
children. What statement does the nurse include on tasks that can be performed by a 6-year-old
child?
"The child can identify missing numbers."
"The child can count 13 pennies without effort."
"The child can count numbers backward from 20 to 1."
"The child knows the days of the week and months in order."
Rationale
A physically and mentally fit 6-year-old child should be able to count 13 pennies and know the
concept of numbers. An 8- to 9-year-old child should be able to count numbers backward from
20 to 1 and know the days of the week and months in order. A 7-year-old child should be able to
identify the missing numbers and pictures in a story or cartoon book.
What instructions would the nurse include when teaching the parents of school-age children
ways to reduce the risk of injury during sports activities? Select all that apply.
Encourage lots of competitive activities.
Discourage participation in sports at this age.
Encourage physical activity outside of sports.
Have children wear helmets and other protective equipment.
Have children compete against kids who are about the same size.
Rationale
When instructing the parents of school-age children in ways to reduce the risk of injury in sports,
the nurse should stress the importance of wearing helmets and proper equipment, competition
with children who are close to the same size, and regular physical activities outside of sports to
keep the children in shape. Discouraging sports participation at this age is not helpful because
most school-age children enjoy sports. Encouraging lots of competitive activities is not
recommended because too much competition at a young age can lead to sport-related injuries.

The nurse is performing annual assessments of height and weight in school children of ages 6 to
12 years. The nurse compares the current assessment findings of height and weight of the
children with the previous year's assessment findings. What changes does the nurse anticipate in
the healthy children?
The 6-year-old children are 75 to 85 cm tall.
The children lost 4.5 to 6.5 pounds on average.
The weight of girls is more when compared to boys.
The 12-year-old children are about 150 to 155 cm tall.
Rationale
The height and weight of children between ages 6 and 12 increases due to the change in bone
growth and density. The height of 12-year-old healthy children is 150 to 155 cm. The weight of
healthy children increases 4.5 to 6.5 pounds or 2 to 3 kg per year. The height of 6-year-old
healthy children is approximately 116 cm. The height and weight of boys are more compared to
girls.

During a home visit, the nurse assesses the growth and development of a 7-year-old child. After
the assessment, the nurse documents that the child's physical development is inadequate. What
physical characteristic supports this finding and documentation?
Decreased leg length in relation to height
Decreased head circumference in relation to height
Decreased waist circumference in relation to height
Increased arm length in relation to other parts of body
Rationale
During middle childhood, the child's physical maturity can be assessed by comparing the growth
of body parts in relation to height. The child is considered to have inadequate physical
development if the leg length is inadequate when compared to the increase in height. A healthy
child with proper physical maturity can be identified by reduced head circumference when
compared to height. Waist circumference is also decreased when compared to height. Healthy
children have longer limbs due to skeletal lengthening.
A nurse is teaching student nurses about the adaptive behaviors exhibited by children at different
stages of development. What statement made by a student nurse indicates the need for further
teaching?
"A 12-year-old child can raise a pet."
"A 7-year-old child can use a table knife for cutting meat."
"A 5-year-old child can brush and comb hair acceptably without help."
"A 9-year-old child can help with routine household tasks such as dusting and sweeping."
Rationale
In general, a 7-year-old child can brush and comb hair acceptably without help; a 5-year-old
child is too young to display such behavior. This statement by the student nurse indicates a need
for further teaching. Children ages 10 to 12 can raise pets. A 7-year-old child can use a table
knife for cutting meat, even though help may be needed with tough or difficult pieces. Children
in the age group of 8 to 9 years can help with routine household tasks such as dusting and
sweeping.

A nurse is teaching student nurses about the social milestones reached by children at different
stages of development. What statement made by a student nurse indicates effective learning?
"A 10-year-old child is a boaster."
"A 7-year-old child develops modesty."
"An 8-year-old child begins to get interested in boy-girl relationships."
"A 6-year-old child plays mostly with groups of the same sex but begins to play with opposite
sex children."
Rationale
Children in the age group of 8 to 9 years start to develop interest in boy-girl relationships, but
will not admit it. Therefore this statement made by the nurse indicates effective learning. A 6-
year-old child is a boaster; children in the age group of 10 to 12 years are more diplomatic.
Children in the age group of 8 to 9 years develop modesty; a 7-year-old child usually does not do
so. Children in the age group of 8 to 9 years play mostly with groups of the same sex, but begin
to mix genders in playgroups; this is not seen in 6-year-old children.

The nurse is assessing a 10-year-old child in a pediatric unit. What changes does the nurse assess
that indicate the child's degree of physical maturity? Select all that apply.
Body muscle functionally mature
Increase in leg length in relation to height
Decrease in head circumference in relation to height
Decrease in waist circumference in relation to height
Decrease in body weight with respect to age-appropriate weight
Rationale
In school-age children physical changes are observed because growth occurs rapidly. The nurse
observes increase in leg length in relation to height, decrease in head circumference in relation to
height, and decrease in waist circumference in relation to height. Body muscle strength increases,
but these muscles are immature when compared with those of adolescents and can more readily
be damaged by muscular injury caused by overuse. At this age the child's body weight increases
due to increase in muscle tissue.
At a community health center, a nurse is explaining age-related behavior and developmental
changes to the parents of a 6-year-old child. What statements made by the nurse are
appropriate? Select all that apply.
"At the age of 6 the child plays a fair game."
"At the age of 6 the child feels more independent."
"At the age of 6 the child follows the actions of adults."
"At the age of 6 the child likes to play with older children."
"At the age of 6 the child feels jealous of younger brothers or sisters."
Rationale
During middle childhood the personal and social development of a child changes. The nurse
should explain the behavioral changes seen in a 6-year-old child to avoid panic in the parents. A
6-year-old child follows the actions of adults, because the child considers elders to be role
models. The child feels more independent, because the child starts exploring things and starts
going to school. The child feels jealous of younger brothers or sisters due to attention-seeking
behavior. To avoid a feeling of inferiority, the child cheats to win games. The child feels
comfortable with peers and avoids playing with older children.

Piaget described a change in the cognitive process of school-age children during the concrete
operational phase. What is the change that helps form the basis for logical thought and the
development and maturation of morality?
Reduction in egocentricity
Mastery over the concept of conservation
Understanding of relationships between things and ideas
Ability to perform actions mentally without the need to carry out the behaviors
Rationale
During the concrete operational period, children acquire the ability to perform cognitive
operations and apply these new skills when thinking about objects, situations, and events. Their
rigid, egocentric outlook is replaced by thought processes that allow them to see things from
another’s point of view. This steady reduction in egocentricity helps to form the basis for logical
thought and the development and maturation of morality. Mastery over the concept of
conservation is one of the major cognitive tasks of school-age children. Children in the concrete
operational phase develop an understanding of relationships between things and ideas. School-
age children are able to articulate the actions involved in the process and perform the actions
mentally without the need to carry out the behavior. However, none of these three skills are
specifically related to forming the basis for logical thought and the development and maturation
of morality.

A nurse provides general guidelines on how parents can discipline their children. Which
statement denotes the appropriate and the most effective method for disciplining school-age
children?
"Taking punitive action is an effective disciplinary technique for school-age children."
"Spanking a child occasionally is acceptable and can help the child stop a forbidden action."
"Disciplining a child makes the child more likely to empathize with the victim of a misdeed."
"Disciplinary techniques are designed to help caregivers control a child’s unacceptable
behavior."
Rationale
One of the major purposes of disciplining a child is to stimulate the child’s ability to empathize
with the victim of a misdeed. Punitive actions are of limited value and are associated with
increasingly disruptive behavior in children. Physically aggressive parenting practices that
involve spanking are linked to children with poor internalizing behaviors including depression,
anxiety, hopelessness, and poor external behaviors such as aggression and violence. As children
are increasingly able to see a situation from the point of view of another, they are able to
understand the effects of their actions on others and themselves. Disciplinary techniques should
be designed to harness this awareness in children and help them control their own behavior.

A mother catches her child stealing money from her handbag. What are the appropriate and
effective responses from the mother in this situation? Select all that apply.
Select all that apply
"Did you steal money from my purse?"
"You will get a spanking for this behavior."
"You have to pay back the money that you took."
"I am disappointed that you took the money without asking me."
"Are you trying to take revenge on me for scolding you yesterday?"
Rationale
An appropriate and reasonable punishment is an effective way of dealing with the situation when
the parent realizes that the child is stealing. Making the older child pay back the stolen money is
an appropriate punishment. A child who is caught stealing should be reprimanded so that it is
clear to the child that such behavior is not acceptable. However, the reprimand should be
reasonable. The statement, "I am disappointed that you took the money without asking me," is an
acceptable response in this situation. It is seldom helpful to trap children into admission by
asking directly if they did the offensive thing, because children do not take on such responsibility
until nearer to the end of middle childhood. Demanding angrily, "Did you steal money from my
purse?" might not be an effective reaction on the mother’s part. Spanking and other forms of
corporal punishment are of limited value and are associated with increasingly disruptive behavior
in children. Although children do sometimes wish for revenge to "get back at someone," usually
a parent, for what they consider to be unfair treatment, in most situations it is best not to attempt
to find a hidden or deep meaning to the stealing.

A nurse discusses with the parents the actions they can take to help their children in school. What
are some of the guidelines the nurse would suggest to the parents? Select all that apply.
Meet the teacher at the beginning of school.
Encourage the child to set goals and achieve high grades daily.
Be involved in helping with homework in any way to foster a habit of independence in the child.
Wait for a scheduled conference to bring up any problem that the child may be facing in school.
Pay attention to the grades that the child is receiving, but do not get involved in what is being
taught in school.
Rationale
The parents should meet the teacher at the beginning of school and plan to visit the school to see
what is taught and expected. Parents should focus on content and major concepts learned versus
grades. Daily questioning of grades could cause stress for the child. Parents can help their
children with homework if needed, as long as the help focuses on explaining the question, and
not giving the answer. The parents should communicate with the teacher if there appears to be a
problem, not wait for a scheduled conference. The parents should demonstrate an interest in what
the child is learning; the focus should be on expressing an interest in the content and growth
more than in grades.

The parents of 9-year-old twins tell the nurse, "They've filled up their bedroom with collections
of rocks, shells, stamps, and cars." The nurse would understand this behavior demonstrates what
for this child?
Giftedness
Typical "twin" behavior
Cognitive development at this age
Psychosocial development at this age
Rationale
Classification skills are developed during the school-age years. This age group enjoys sorting
objects according to shared characteristics. Giftedness is not measured simply by a school-age
child's ability to classify objects, which is an expected cognitive skill for this age group.
Giftedness signs include specific academic aptitudes, advanced memory skills, creative thinking,
ability in the visual or performing arts, and psychomotor ability, either individually or in
combination. The development of classification skills is characteristic of the school-age child
and is not related to the behavior of twins. Psychosocial development of the school-age child is
focused on accomplishment or industry, not the cognitive skills of classification that are
described.

A nurse is teaching student nurses about cognitive milestones reached by average American
children at different stages of development. What statement made by a student nurse indicates
effective learning?
"A 5-year-old child can repeat three numbers backward."
"An 8-year-old child can describe common objects in detail."
"A 7-year-old child can give similarities and differences between two things from memory."
"A 6-year-old child can read an ordinary clock or watch correctly to the nearest quarter hour."
Rationale
An 8-year-old child can describe common objects in detail, and not merely enumerate their use.
A 7-year-old child can repeat three numbers backward; a 5-year-old child usually cannot.
Children in the age group of 8 to 9 years can give similarities and differences between two things
from memory; a 7-year-old child usually cannot. A 7-year-old child can read an ordinary clock
or watch correctly to the nearest quarter hour; a 6-year-old child usually cannot.

The nurse is teaching a community health promotion class to parents and school-age children
related to bicycle safety. What information would be included in this educational session?
Walking bicycles through busy intersections
Installing reflectors only on bicycles that are to be ridden at night
Wearing a bicycle helmet only if the child is planning to ride in traffic
Riding bicycles against, rather than with, traffic so the rider can see the cars
Rationale
Bicycles should be walked through busy intersections to allow the child to have full view of the
traffic and be able to react accordingly, with safety the number one priority. Bicycle helmets
should be worn at all times to prevent head injuries. Reflectors should be installed on all
bicycles, whether they are ridden during the daytime or at night only. Bicycles should always be
ridden with the traffic, not against the traffic. This will help prevent accidents.

The nurse is teaching parents and their child about health promotion. What interventions to
promote health during middle childhood would be included?
Instructing parents to defer questions about sex until the child reaches adolescence
Stressing the need for increased calorie intake to meet the increased demands on the body
Advising parents that the child will need decreasing amounts of rest toward the end of this period
Educating the child and parents about the need for effective dental hygiene because these are the
years in which permanent teeth erupt
Rationale
Because the permanent teeth are present, it is important for the child to learn how to care for
them. Parents should approach sex education with a life span approach and answer questions in a
manner appropriate for the child's age. Caloric needs are diminished in relation to body size
during the middle years; however, a balanced diet is important to prepare for the adolescent
growth spurt. School-age children often need to be reminded to go to sleep.

A parent tells the nurse, "I'm worried about my 13-year-old son. He hasn't started puberty, but
my daughter did when she was 11 years old." What is the appropriate explanation by the nurse?
"This is unusual and requires further evaluation of your son."
"This is unusual because the onset of pubescence is usually the same in siblings."
"This is normal because the onset of pubescence is usually earlier in girls than it is in boys."
"This is abnormal because the onset of pubescence is usually earlier in boys than it is in girls."
Rationale
Girls begin puberty on average approximately 2 years before boys. Puberty usually begins no
earlier than age 12 years in boys, with an average age of onset of 14 years; therefore onset of
puberty is not abnormal in this case, and no further evaluation is necessary at this time.

The parents of a 12-year-old child complain to the nurse that the child asks them about
masturbation after watching a contraceptive advertisement. The parents are anxious about how to
respond to their child’s questions. What response by the nurse helps relieve the parents' anxiety?
It is an age-associated behavior.
The child has a mental disorder.
The child has a hormonal disorder.
The child needs psychiatric treatment.
Rationale
The nurse tells the parents that masturbation is common in school-aged children due to hormonal
changes in the body. The parents should have a good relationship with the child and provide sex
education. Curiosity about sex does not indicate that the child has a mental, hormonal, or
psychiatric disorder.

A group of boys has formed a club that is open to other boys who like to play sports. What is this
behavior considered?
Bullying
Promoting gang violence
Promoting isolation and exclusion
Normal social development of school-age children
Rationale
One of the outstanding characteristics of middle childhood is the creation of formalized
groups or clubs. Peer-group identification and association are essential to a child's socialization.
Poor relationships with peers and a lack of group identification can contribute to bullying. Poor
relationships with peers can promote gang violence and isolation or exclusion.

What is the average age of second permanent molar eruption in the child?
6 to 7 years
7 to 8 years
10 to 11 years
12 to 13 years
Rationale
Tooth eruption occurs at specific ages. Second molar eruption in the upper jaw occurs at the age
of 12 to 13 years old. First molar eruption occurs between 6 and 7 years of age. Central incisor
eruption occurs between 7 and 8 years of age. First bicuspid eruption occurs between 10 and 11
years of age.

What characteristic is often observed in latchkey children?

They are brave.
They have confidence.
They bully other children.
They feel isolated and lonely.
Rationale
Children who are left to care for themselves before or after school without adult supervision are
called latchkey children. These children feel isolated and do not interact with their peers. They
are not brave but fearful. These children do not prefer to socialize with peers. It is very unlikely
that they bully others; instead they are bullied by other children. As they feel lonely, they are less
likely to be confident.

Chapter 17
Why do peer relationships play a significant role during adolescence?
Adolescents dislike their parents.
To provide a source of social reinforcement.
Adolescents no longer need parental control.
To promote a sense of individuality in adolescents.
Rationale
The peer group serves as a credible source of information, role model for new social behaviors, a
source of social reinforcement, and a bridge to alternative lifestyles. During adolescence the
parent-child relationship changes from one of protection-dependency to one of mutual affection
and equality. Parents continue to play an important role in personal and health-related decisions.
The peer group forms the transitional world between dependence and autonomy.
The nurse is reviewing puberty stages with a group of student nurses. At what age would she
instruct the students to be concerned with a delay in puberty in girls?
No breast development by age 10 and absence of menarche
No breast development by age 11 and absence of menarche
No breast development by age 12 and absence of menarche
No breast development by age 13 and absence of menarche
Rationale
One should be concerned about puberty delay in girls if there is no breast development by age 13
and an absence of menarche. The absence of breast development or menarche by age 10, 11, and
12 is not considered puberty delay in girls.

A 14-year-old adolescent male tells a nurse, "My trunk seems so short compared to my legs. Do I
have some kind of problem?" What is the appropriate response by the nurse?
"You are completely normal."
"You should do a lot of exercises."
"You may be required to take growth pills."
"You should have your testosterone levels checked."
Rationale
Growth in the length of the body in adolescent males follows a specific sequence. The
extremities grow first, followed by the trunk. Thus, adolescent males have a gawky appearance,
with long limbs and a short trunk. The person does not have any health-related problem;
therefore the nurse should not recommend exercise as a remedy. The differences in the lengths of
body parts are not abnormal in this situation, and the nurse need not ask the patient to take
growth pills. Because the patient has normal growth, the nurse should not advise the patient to
have testosterone levels checked.

After receiving the immunization history of a 12-year-old female, the nurse plans to administer
the (human papillomavirus) HPV vaccine. The nurse is aware the goal of administration of the
HPV is to prevent what?
Meningitis
Pertussis
Genital warts
Cervical cancers
Rationale
Human papillomavirus vaccine is used for the prevention of cervical cancers in females. HPV
does not prevent meningitis or pertussis. The meningococcal vaccine (MCV) is given for the
prevention of meningitis. The DTaP (diphtheria, tetanus, acellular pertussis) vaccine is used for
the prevention of pertussis. HPV vaccine is used to reduce the likelihood of genital warts in
males.

An 18-year-old tells the nurse, "My friend got a cool tattoo around the belly button. I'm planning
to get one too." What is the appropriate response by the nurse?
"I don't think it is cool; it has too many risks of infections with it."
"You should consider going to a professional who uses a sterile technique."
"You should ask your parents' permission first and get a note to have it done."
"You will contract human immunodeficiency virus (HIV) if you get a tattoo there."
Rationale
The nurse advises the teenager to get the tattoo done by a professional who uses a sterile
technique so that there is no risk for infections or other side effects. Asking the teenager to get
permission from the parents is inappropriate, because they may be against it, which may cause
conflict. To say that tattooing is not cool and has many risks may make the teenager defiant;
instead the nurse advises the teenager to have it done safely. Saying that tattooing will cause HIV
is inappropriate. Instead the nurse says that it may cause HIV if a sterile technique is not used.

What assessment finding demonstrates the onset of puberty in an adolescent boy?

Voice changes
Testicular enlargement
Growth of dark pubic hair
Increased size of the penis
Rationale
Testicular enlargement is the first change that signals puberty in boys during Tanner stage 2 of
sexual development. Voice changes occur between Tanner stages 3 and 4 of sexual development.
Fine pubic hair may develop at the base of the penis early in puberty, but darker hair grows in
during Tanner stage 3 of sexual development. The penis enlarges during Tanner stage 3 of sexual
development.

What dimensions would be included in any consideration of an adolescent's sexual

orientation? Select all that apply.
Attraction
Fantasy
Masturbation
Actual sexual behavior
Self-labeling or group affiliation
Rationale
When considering an adolescent's sexual orientation the nurse should include the dimensions of
attraction, fantasy, actual sexual behavior, and self-labeling or group affiliation. Whether the
adolescent engages in masturbation is not considered a dimension of sexual orientation.

What normal physiologic changes occur in children due to puberty changes? Select all that
apply.
Pulse rate decreases.
Respiratory volume increases.
Strength of the heart increases.
Basal heat production increases.
Systolic blood pressure increases.
Rationale
The size and strength of the heart increase after puberty; this increases systolic blood pressure
and decreases pulse rate. Respiratory volume increases after puberty to a greater extent in males
than in females. Basal heat production decreases due to puberty changes.
While caring for hospitalized adolescents, the nurse observes that sometimes teenagers are
skeptical of their parents' religious beliefs and practices. What would the nurse recognize as
about this behavior?
Normal spiritual development for age
The children lack spiritual development
This is related to illness and occurs only in times of crisis
The parents’ have an inability to adequately explain their beliefs and practices
Rationale
Adolescents reexamine and reevaluate many of the beliefs and values of their childhood.
Adolescents try to determine which of their parents' standards and beliefs to incorporate into
their own. The behavior described is not abnormal, nor is it applicable only during times of
crisis. The behavior described is not related to the parents' inability to explain their beliefs and
practices.

The school nurse is teaching a class on injury prevention. What would be included in a
discussion of firearms for a group of adolescents?
Adolescents are too young to use guns properly for hunting.
Carrying of guns is on the rise among adolescents, primarily inner-city youth.
Adolescence is the peak age for being a victim or an offender in a firearm injury.
Nonpowder guns (air rifles, BB guns) are relatively safe alternatives to powder guns.
Rationale
Gun carrying among adolescents is on the rise. The increase in gun availability is linked to
increased gun injuries and deaths among children. Adolescents can be taught to safely use and
store guns for hunting. Gun carrying is on the rise among all adolescents and is not limited to the
stereotype of inner-city youth. Nonpowder guns, such as air rifles and BB guns, cause almost as
many injuries as do powder guns.

What question does a nurse ask a 14-year-old patient to determine whether a varicella
vaccination is needed?
"Have you ever had chickenpox?"
"Have you taken the tetanus booster?"
"Are you taking any antibiotic drugs?"
"Are the surroundings around your home clean?"
Rationale
Varicella vaccination is given to adolescents who do not have a history of varicella infection
(chickenpox). The nurse need not ask about tetanus immunization, because the vaccines do not
interact with each other. Antibiotic drugs are not known to interact with the varicella vaccine.
People living in unhygienic surroundings should undergo a tuberculin test.

What description characterizes normal cognition during the period of early adolescence (11 to 14
years)?
Development of capacity for abstract thinking
Ability to perceive and act on long-range options
Enjoyment of intellectual powers, often in idealistic terms
Exploration of new-found ability for limited abstract thought
Rationale
During the period of early adolescence (11 to 14 years), normal cognition is characterized by
exploration of new-found ability to engage in limited abstract thought. Development of capacity
for abstract thinking does not occur until middle adolescence (15 to 17 years). Perception and
action on long-range options does not occur until late adolescence (18 to 20 years). Enjoyment of
intellectual powers, often in idealistic terms, does not occur until middle adolescence (15 to 17
years).

What is a recommended screening practice for sexually active adolescents?

Both males and females should have laboratory tests for gonorrhea.
Only females should be evaluated for human papillomavirus (HPV) by visual inspection.
Both males and females should have Papanicolaou (Pap) test to detect human papillomavirus
(HPV) infection.
Only males should be evaluated for syphilis if they have had more than one sexual partner within
the past 2 years.
Rationale
All sexually active teenagers should be tested for sexually transmitted infections like gonorrhea.
Both males and females, if sexually active, should be evaluated for HPV by visual inspection and
should also be asked whether they have received the HPV vaccine series. Only sexually active
females should receive a Pap test to detect HPV infection or other cervical dysplasia. Both males
and females should have a serologic test for syphilis if they are sexually active; also, the test
should be performed if they have had more than one sexual partner within the past 6 months.

What is the growth difference between girls and boys related to puberty?
Growth in height ceases around age 16 for boys.
There is no consistent pattern between boys and girls.
Growth in height ceases 2 to 2½ years after menarche in girls.
The height/growth spurt in boys occurs earlier than the growth spurt in girls.
Rationale
On average, a girl's height ceases to increase 2 to 2½ years after menarche. Puberty involves a
predictable sequence of physical changes. Girls reach their peak growth an average of 2 years
earlier than boys. Growth in height ceases between 18 and 20 years old for boys, not 16 years.

Adolescence is the peak age for being either a victim or an offender in injuries involving what?
Falls
Firearms
Drowning
Motor vehicles
Rationale
Adolescence is the peak age for being either a victim of or an offender in injuries involving
firearms. Falls do not peak during adolescence. Drowning is more common among younger
children than in adolescents. Motor vehicle injuries are common at all ages.

What statement is true about the developmental stages of secondary sexual characteristics and
genital development in boys?
Initial enlargement of penis occurs at Tanner stage 4.
Initial enlargement of scrotum and testes occurs at Tanner stage 3.
Slightly pigmented hair forms at the base of the penis at Tanner stage 2.
Pubic hair growth remains restricted to the pubic area at Tanner stage 5.
Rationale
During the Tanner stage 2 or the puberty stage, sparse growth of long, straight, downy, and
slightly pigmented hair occurs at the base of the penis. Initial enlargement of the penis, mainly in
length, occurs at Tanner stage 3; at stage 4, the penis increases further in length and also grows
in diameter. Initial enlargement of scrotum and testes occurs at Tanner stage 2, or the puberty
stage; during stage 3, testes and scrotum are further enlarged. Pubic hair growth remains
restricted to the pubic area until Tanner stage 4; during stage 5, the pubic hair spreads to inner
surface of thighs.

The nurse is assessing the sexual development of a female child. The nurse finds that breast buds
have started developing, but pubic hair is still not visible in the child. What does the nurse
document as this assessment finding achieved at this exam?
Menarche
Puberty
Thelarche
Adrenarche
Rationale
Sexual development begins with the development of breast buds in a female. This event is
known as thelarche. The female child has not started having menses, so the nurse cannot infer
that the female has attained menarche. Development of breast buds indicates the beginning of the
process of puberty. Puberty is attained when a girl has her first menstrual flow. Adrenarche
refers to the event in which there is growth of pubic hair around the mons pubis. This child does
not have any pubic hair, so the child has not attained adrenarche.

A nursing instructor discusses with student nurses effective strategies to teach adolescents
responsible sexual behavior. What strategy offered by a student nurse demonstrates the need for
further teaching?
Providing abstinence-only sexual health education
Counseling adolescents on methods of birth control
Discussing about limiting the number of sexual partners
Providing positive reinforcement for consistent condom use
Rationale
Extensive government funding has been available to provide abstinence-only sexual health
education over the past decade. However, research evidence shows most such programs are not
effective in delaying sexual behavior and may actually increase unprotected sex among
adolescents once they become sexually active. Counseling adolescents on how to use condoms
and other methods of birth control effectively is an appropriate strategy in this case. It is also an
effective strategy to discuss with sexually active adolescents the ways to reduce their risk of
sexually transmitted infections and unwanted pregnancy, including limiting the number of sexual
partners they have. Adolescents should receive positive reinforcement for responsible sexual
behaviors, including consistent condom use.

What nursing care guidelines would be used when the nurse is interviewing adolescents? Select
all that apply.
Using adolescent slang
Ensuring confidentiality and privacy
Interviewing adolescents with their parents
Maintaining objectivity and avoiding judgments
Offering a nonthreatening explanation for the questions asked
Rationale
When interviewing adolescents it is important for the nurse to ensure confidentiality and privacy.
Offering a nonthreatening explanation for the questions asked, such as, "First I'd like to talk
about your main concerns," is helpful. It is also important to maintain objectivity and avoid
judgments. Slang should be avoided; instead, terms that both the nurse and the adolescent
understand should be used. It is important to interview adolescents without their parents.

What is the most effective nursing action during adolescent health screening to help exhibit
health-promoting behavior?
Building trusting relationships with adolescents
Directing adolescents to resources appropriate in their community
Teaching adolescents how to schedule their health care appointments
Identifying both assets and threats to an adolescent’s health and well-being
Rationale
The health screening interview offers an opportunity for health professionals to build trusting
relationships with adolescents. This sense of trust prompts the adolescents to act on information,
attitudes, and skills that are shared to help them successfully negotiate particular stressors. The
health screening interview provides an opportunity for teaching adolescents self-advocacy skills;
one strategy for doing this is to direct adolescents to resources in their community and to
appropriate, accurate sources of health information on the internet. Teaching adolescents how to
schedule their health care appointments is another strategy the nurse can employ to teach the
adolescents self-advocacy skills. Both assets and threats to an adolescent’s health and well-being
can be identified through information gained during a health screening interview. However, none
of these three are the most effective action that the nurse can take that would influence the
adolescents to act on the information and skills shared with them.

How is moral development in late adolescence typically characterized?

Serious questioning of existing moral values
Acceptance of the decisions or point of view of parents
Adoption of their parents' set of moral values and beliefs
Basing of decisions on an externalized set of moral principles
Rationale
Moral development in late adolescence is best characterized by serious questioning of existing
moral values. Adolescents no longer accept the decisions or points of view of their parents or the
adults around them. They do not typically adopt all of their parents' set of moral values and
beliefs. They also base decisions on an internalized, rather than an externalized, set of moral
principles.

The nurse is assessing the health status of an adolescent. What guidelines for adolescent health
does the nurse take into consideration during the assessment? Select all that apply.
Avoid assumptions, judgments, and lectures.
Use language that the adolescent understands.
Show concern for the adolescent's perspective.
Ask the parents to accompany their adolescent.
Offer a nonthreatening explanation for the questions.
Rationale
The nurse shows concern for the adolescent's perspective to build trust. The nurse offers a
nonthreatening explanation for the questions that are asked so that the adolescent is not anxious
and understands the purpose of the interview. The nurse avoids assumptions, judgments, and
lectures to maintain objectivity. The nurse uses language that the adolescent understands to
reduce confusion and obtain concise answers. The nurse interviews the adolescent without the
parents to ensure confidentiality and privacy.

The nurse is assessing the social factors that influence an adolescent. What factors would the
nurse include in the assessment? Select all that apply.
Adolescent’s gender
Interests and activities
Relationships with peers
Relationships with parents
Self-concept and body image
Rationale
The relationship of adolescents with their parents changes to mutual affection and equality
during adolescence. There may be conflicts between parents and adolescents, because
adolescents want to be free of parental restraints. Peer groups have intense influence on
adolescents' behavior and also influence their decision making. Leisure time activities also help
in the development of social, physical, and cognitive skills of the adolescent. Gender is not a
social factor. Self-concept and body image are not social factors but are more related to how the
adolescent feels about the new changes that have taken place in the body.

A student nurse compares the relationships with parents in early adolescence, middle
adolescence, and late adolescence. What relationship features belong particularly to middle
adolescence? Select all that apply.
Emancipation nearly secured
Greatest push for emancipation
Major conflicts over independence and control
Mourning an irreversible emotional detachment from parents
Strong desire to remain dependent on parents while trying to detach
Rationale
Middle adolescence is when there is the greatest push for emancipation as well as major conflicts
with parents over independence and control; early adolescence has no major conflicts over
parental control, and late adolescence is characterized by less conflict. Middle adolescence also
sees a final and irreversible emotional detachment from the parents, along with the mourning
associated with it. Emancipation is nearly secured in late adolescence; in middle adolescence, the
push is the greatest. A strong desire to remain dependent on parents while trying to detach is seen
in early adolescence; middle adolescence, instead, is characterized by disengagement.
A student nurse compares the issues associated with identity in boys and girls through different
stages of adolescence. What statement indicates the student understands the role identity?
"A late adolescent tries out various roles."
"An early adolescent sees an increase in self-esteem."
"A middle adolescent is comfortable with physical growth."
"An early adolescent meticulously conforms to group norms."
Rationale
An early adolescent thoroughly conforms to group norms; a middle adolescent is self-centered
and narcissistic, and a late adolescent has defined and articulated social roles. Late adolescence is
the phase of consolidation of identity; the late adolescent has defined social and gender identity,
whereas an early adolescent tries out various roles. Self-esteem decreases in early adolescence;
late adolescence sees an increase in self-esteem. Middle adolescents modify their body image; a
late adolescent is comfortable with physical growth.

A nurse is interviewing an adolescent during a health screening. What statements made by the
nurse show effective communication techniques employed in this situation? Select all that
apply.
"What you did was wrong."
"What do you think is happening?"
"I would like to talk about your main concerns."
"I would like to interview you in the presence of your parents."
"So you didn’t know this could happen; you must be feeling pretty confused about all this."
Rationale
The nurse needs to show concern for the adolescent’s perspective while interviewing the
adolescent during a health visit. The question, "What do you think is happening?" is an
appropriate one. In the same way, the statement, "I would like to talk about your main concerns"
focuses on the adolescent’s perspective and is also appropriate. Another effective technique is to
reflect back to the adolescent on what the adolescent has said, along with any feelings that may
be associated with the descriptions. This is demonstrated through the statement, "So you didn’t
know this could happen; you must be feeling pretty confused about all this." The nurse needs to
maintain objectivity and avoid being judgmental. The statement, "What you did was wrong" is
inappropriate in this situation. The nurse also needs to ensure confidentiality and privacy; this
can be done by interviewing the adolescent alone without the parents in the room. Hence, the
statement, "I would like to interview you in the presence of your parents" is not an effective one.

An adolescent tells the nurse "I grew up in a rural area and have recently moved to New York
City. I don't feel like I fit in. I really find it difficult to make friends here." What response by the
nurse is appropriate in this situation?
"You should go online to find friends."
"You should change schools to find more friends."
"You should join a club at school in your free time."
"You should read up about the things that your peers talk about."
Rationale
Leisure activities are at the center of adolescents' social lives, so the nurse may suggest that the
student join a club at school that will put the adolescent in more frequent contact with
classmates. A nurse would not likely encourage an adolescent to try to find friends online
because of the increasing dangers of online predators and the risks of sharing personal
information online. The nurse would not necessarily encourage the student to change schools
because this is a decision that should be made by the student and parents, and would not
automatically help the adolescent adjust to life in a larger city. Reading about the topics
mentioned by peers will not necessarily help the student make friends and feel more socially
adjusted.

A nurse is screening adolescents for possible mental health issues. What statement regarding
mental health in the adolescent is accurate?
"Adolescents who have depression always look depressed."
"Being alone for long periods of time is strongly indicative of depression."
"Feeling down or blue for some time can mean that the adolescent has depression."
"Adolescents who have a strong sense of invulnerability in their personal fable are more prone to
depression."
Rationale
Most adolescents who are depressed respond affirmatively when asked whether they have been
feeling down or blue lately. Even though adolescents with depression often report feeling "blue,"
"down," or "depressed," they may not necessarily look depressed. Being alone can be a method
of coping with stress in adolescents; it may indicate an attempt to cope with depression as well,
though it is not always so. Adolescents with a strong sense of invulnerability in their personal
fable are more likely to engage in risky behaviors that can lead to injury, while the ones whose
personal fable is focused on their uniqueness may be at higher risk for depression and suicidal
ideation.

Girls experience an increase in weight and fat deposition during puberty. How would a nurse
provide information to a teenage girl who is concerned with an increase in her weight since
starting her periods?
Giving reassurance that these changes are normal
Suggesting dietary measures to control weight gain
Encouraging a low-fat diet to prevent fat deposition
Recommending increased exercise to control weight gain
Rationale
A certain amount of fat is deposited, along with increases in lean body mass, to fill the
characteristic contours of the child's sex. A healthy balance must be achieved between expected
healthy weight gain and obesity as related to these normal and expected physical changes. A diet
should not be encouraged unless weight gain is excessive; eating disorders can develop in this
group, and diet management should be considered only under a health care provider's care.
Menarche is delayed in the girl with body fat content that is too low; therefore a low-fat diet is
not a recommended intervention. Exercise is an important component in weight management but
should never be done or encouraged in increased amounts or in excess to control weight gain that
occurs normally during puberty. Some fat deposition is essential for normal hormonal regulation.

What statement made by an adolescent indicates to the nurse that they are couch surfing?
"I often get high and have exchanged sex for drugs or money."
"I like to spend long periods of time alone in my room when I feel stressed."
"I often snack on fried food and carbonated drinks as I relax on the couch and watch television."
"I stay at my friends’ houses because my parents are always fighting and I don’t want to stay
with them."
Rationale
Adolescents who live in homes where there is constant conflict may run away, sometimes to a
friend’s home. The term couch surfing is used in some circles to refer to the adolescent who
spends time at different friends’ houses sleeping on a couch or in an available spare room to
"crash" temporarily. The nurse needs to assess problem use in adolescents and ask them about
how often they get "high" or "wasted" and also about the use of tobacco, alcohol, marijuana, or
other substances in relation to sexual activity, because this pattern of use can endanger them.
However, this is unrelated to couch surfing. Adolescents often try to cope with stress by
spending periods of time alone. This is a normal behavior and is unrelated to couch
surfing. Snacking on empty calories is common among adolescents, especially during inactivity.
This is not related to couch surfing.

A student nurse compares the relationships with peers in early, middle, and late adolescence. The
student demonstrates understanding when she includes what relationship as particular to middle
adolescence? Select all that apply.
Ability to attract opposite sex is explored.
Behavioral standards are set by peer group.
Relationships become characterized by giving and sharing.
Individual friendship is given more importance than peer group.
Upsurge of close, idealized friendships with members of same sex occurs.
Rationale
Particular to relationships with peers during middle adolescence is the exploration of the ability
to attract the opposite sex; early adolescence is characterized by idealized friendships with
members of the same sex, while late adolescence sees the testing of romantic relationships
against the possibility of permanent alliance. In middle adolescence, behavioral standards are set
by the peer group and acceptance by peers is extremely important; early adolescence sees a
struggle for mastery within the peer group, and late adolescence focuses more on individual
relationships. Relationships become characterized by giving and sharing in late adolescence; this
is not a feature of middle adolescence. Individual friendship is given more importance than peer
group in late adolescence; middle adolescence is strongly connected to the peer group.

A student nurse compares the issues associated with sexuality in boys and girls through different
stages of adolescence. What statement is accurate related to romantic relationships in
adolescence?
"Dating as a romantic pair is seen in middle adolescence."
"A feeling of ‘being in love’ is common in middle adolescence."
"Tentative establishment of relationships occurs at early adolescence."
"Public identification as being gay, lesbian, or bisexual occurs at middle adolescence."
Rationale
A feeling of " being in love" is common in middle adolescence. In early adolescence, there is
self-exploration and limited dating and intimacy. In late adolescence, intimacy involves
commitment rather than exploration and romanticism. Dating as a romantic pair is seen in late
adolescence; in early adolescence, there is limited dating, and in middle adolescence, there are
multiple plural relationships. Tentative establishment of relationships occurs in middle
adolescence; early adolescence involves limited dating and intimacy, while late adolescence is
characterized by stable relationships and attachment to another. Public identification as being
gay, lesbian, or bisexual occurs in late adolescence; in middle adolescence, there is internal
identification of heterosexual, homosexual, or bisexual attractions.

What statement is true regarding the changes that start with puberty in females?
A mature ovum is released at menarche.
The primary sexual characteristic in girls is the development of breasts.
The involution of the follicle leads to increased production of follicle-stimulating hormone
(FSH).
The release of the ovum is facilitated by the increased progesterone levels during the follicular
phase.
Rationale
The follicle involutes after ovulation, and its estrogen production decreases. The resultant drop in
serum estrogen and progesterone leads the pituitary gland to respond with increased production
of FSH. This starts a new menstrual cycle. Menarche or the first menstruation occurs when the
endometrial lining of the uterus, caused by high estrogen levels, breaks down. However, the ova
are generally not mature enough to be released at menarche. These start releasing as puberty
progresses. The primary sexual characteristic in girls is the development and release of an egg, or
ovum, from the ovaries approximately every 28 days. Breast development is a secondary sexual
characteristic. During the early-cycle follicular phase, one ovarian follicle becomes dominant
during each menstrual cycle and produces increasing amounts of estrogen.

A nurse is conducting an assessment of a teenage girl. Upon assessing the girl's external genitalia
the nurse notes a clear to white discharge. What condition is this girl experiencing?
Cancer
Leukorrhea
Dysmenorrhea
Abnormal finding
Rationale
Leukorrhea is the term used to describe a clear to white discharge; it may be caused by physical,
chemical, or infectious agents. This discharge is not linked to cancer. Dysmenorrhea is the term
used to describe discomfort during the first day or two of menstrual flow. Leukorrhea is a normal
finding that occurs with hormonal changes in puberty.

A nurse is completing an annual physical exam of a teenage girl. The nurse notes that the girl has
dark, coarse, and curly pubic hair that is spread sparsely over the entire pubis in the typical
female triangle. She also has enlargement of breast and areola with no separation of their
contours. What is the appropriate Tanner stage to document for this patient?
Stage 1
Stage 2
Stage 3
Stage 4
Rationale
Tanner stage 3 is characterized by dark, coarse, and curly pubic hair that is spread sparsely over
the entire pubis in the typical female triangle. There is also some enlargement of breast and
areola with no separation of their contours in this stage. The girl is not in stage 1, because stage 1
is characterized by no pubic hair and elevation of the papilla only. The girl is not in stage 2; stage
2 is characterized by sparse growth of long, straight, downy, and slightly pigmented hair
extending along the labia. Between stages 2 and 3, hair begins to appear on the pubis. Stage 2 of
breast development is characterized by small area of elevation around the papilla, as well as
enlargement of areolar diameter. The girl is not in stage 4, which is characterized by pubic hair
that is denser, curled, and adult in distribution but less abundant and restricted to the pubic area.
In terms of breast development, stage 4 is characterized by projection of the areola and papilla to
form a secondary mound.

A nurse is examining an adolescent male during a physical. The nurse notes that the penis is
longer than what it had been in childhood, the scrotum is darker in color, and the pubic region
has coarse, dark, curly hair. The hair is spread over the pubic area. It is further seen that the penis
had enlarged in both length and breath. What Tanner stage does the nurse document for the
assessment?
Stage 2
Stage 3
Stage 4
Stage 5
Rationale
The boy is in Tanner stage 4. The scrotal skin becomes darker for the first time in stage 4, and
the penis increases in size with growth in diameter and development of glans. The boy is not in
stage 2, because the penis does not enlarge at this stage; only the scrotum does. Also, there is
sparse growth of long, straight, downy, and slightly pigmented hair at the base of penis, and not
coarse, dark hair over the entire pubic region. The boy is not in stage 3, because this stage is
categorized by initial enlargement of the penis, but the enlargement is of length and not breath.
Development of the glans is not seen at this stage. The boy is not in stage 5, because at this point,
the testes, scrotum, and penis all reach their adult size and shape. Also, pubic hair is adult in
quantity and type; it spreads to the inner surface of thighs and is no longer restricted only to the
pubic area.

The primary health care provider asks a nurse to assess and document the Tanner stage of
puberty development in an adolescent female. What would the nurse include in the
assessment? Select all that apply.
The size of the vagina
The growth of body hair
The length of the clitoris
The development of breasts
The distribution of pubic hair
Rationale
The Tanner stages describe the stages of puberty growth in males and females. In order to
determine the stage of puberty growth in females, the nurse should assess the distribution of
pubic hair and the development of breasts. Assessment of the size of the vagina is not a part of
determination of Tanner stages of puberty development. Development of the clitoris is not a
major determining factor of puberty development. The growth of body hair is variable in the
population and is not used to determine the sexual development of an individual.
A 13-year-old boy is concerned about bilateral breast enlargement. What is the basis of
knowledge for the response by the nurse?
Too much body fat
Hormonal imbalance
Indication of precocious puberty
Normal occurrence during puberty
Rationale
Gynecomastia, or enlargement of the breast tissue, occurs during midpuberty in about one third
of boys. In most boys the breast enlargement disappears within 2 years. Although overweight
boys may have excess body weight in the breast area, in boys of normal body weight
gynecomastia is a normal occurrence during puberty. If gynecomastia persists beyond 2 years, a
hormonal cause may need to be investigated. Precocious puberty is the early onset of puberty,
before age 9 years in boys, and is not related to the gynecomastia.

The nursing instructor is teaching a group of students about sexual maturation in boys. What is
included in the teaching? Select all that apply.
Pubescent changes occur between 9½ and 14 years of age.
Testicular enlargement is the last pubescent change in boys.
Sometimes there is temporary breast enlargement in midpuberty.
Early puberty can be identified with the initial appearance of pubic hair.
Increasing muscularity and voice changes are characteristics of puberty.
Rationale
Pubescent changes in boys occur between 9½ and 14 years of age. There is testicular
enlargement and thinning, reddening, and looseness of the scrotum during this period. The initial
appearance of pubic hair, increasing muscularity, and voice changes also indicate pubescent
changes. Temporary breast enlargement or tenderness called gynecomastia occurs in one third of
the boys in midpuberty. Testicular enlargement is the first pubescent change in boys.

A nurse discusses the Tanner stages of puberty development in females with student nurses.
What statement made by a student nurse indicates effective learning?
"Stage 1 shows enlargement of areolar diameter."
"Stage 4 shows projection of areola and papilla to form a secondary mound."
"Stage 2 shows enlargement of breast and areola with no separation of their contours."
"Stage 3 shows projection of papilla only caused by recession of areola into general contour."
Rationale
Stage 4 of breast development at puberty shows projection of areola and papilla to form a
secondary mound; however, this may not occur in all girls. Stage 1 shows elevation of papilla
only; enlargement of areolar diameter is seen in stage 2. Stage 3 shows enlargement of breast and
areola with no separation of their contours; stage 2 shows a small area of elevation around the
papilla. Stage 5 shows mature configuration, which is characterized by projection of papilla only
caused by recession of areola into general contour.

The nurse is administering a meningococcal vaccine to a 12-year-old adolescent. What teaching

does the nurse give to the patient regarding this vaccination?
"You will need a booster dose after 4 years."
"You do not need a booster dose of this vaccine."
"You will have a booster dose on an annual basis."
"You need a second booster dose between 13 and 18 years of age."
Rationale
The first dose of meningococcal vaccine is usually given at 11 to 12 years of age. The next
booster dose of the vaccine has is to be administered when the patient is 16 years of age, which is
4 years after the initial dose. If the patient has not received the meningococcal vaccine at 11 to
12 years of age, the patient has to take only one dose of the vaccine between 13 and 18 years.
This vaccine is not administered annually.

What statement correctly describes the normal pattern of growth in boys and girls during
puberty, when the two growth patterns are compared?
"A puberty growth spurt at 14 years is normal for a girl, while 15½ is normal for a boy."
"The rate of muscle mass growth in both boys and girls continues to increase throughout
puberty."
"Weight and height spurts occur simultaneously for girls, whereas for boys, height spurts occurs
after weight spurts."
"Growth in girls’ height ceases 6 to 12 months after menarche, while growth in boys’ height
ceases at 18 or 20 years of age."
Rationale
The puberty growth spurt begins as early as 9½ years or as late as 14½ years in girls, and as early
as 10½ years or as late as 16 years in boys. A puberty growth spurt at 14 years is normal for a
girl, while 15½ is normal for a boy, because these values fall within the normal range in both
cases. For girls, the rate of muscle mass growth peaks at menarche and then stops; for boys,
muscle mass continues to increase throughout puberty. For girls, the weight spurt occurs about 6
months after the peak height velocity, which in turn occurs about 6 to 12 months before
menarche. Height and weight spurts occur simultaneously for boys. Whereas the growth in boys’
height does cease at 18 to 20 years of age, growth in girls’ height peaks 6 to 12 months before
menarche, and ceases 2 to 2½ years after menarche.

Following the assessment of a 15-year-old adolescent boy, the nurse documents a delay in
puberty for this patient. What assessment finding has led the nurse to this conclusion?
The patient has less body hair.
The patient has a small penis.
The patient has a low-pitched voice.
The patient does not have an enlarged scrotum.
Rationale
If a male has not developed a scrotum by the age of 13 to 14, the male is diagnosed with a delay
in puberty. Body hair does not determine pubertal development in males. Therefore having less
body hair does not indicate that the male has a delay in puberty. Lengthening and widening of
the penis usually occurs in the late puberty phase. Therefore a small penis size does not indicate
that the patient has a delay in puberty. Hoarsening or having a low-pitched voice is a
manifestation of sexual development in males.

A nurse is teaching student nurses about puberty and sexual maturation in males. What statement
made by the student nurses indicates effective learning?
"Gynecomastia in pubescent boys is not a cause for concern."
"The primary sexual characteristic in males is testicular enlargement."
"An adolescent male is considered potentially fertile with the first penile erection."
"Exposure to chemicals can cause precocious puberty in boys less than 9 years of age."
Rationale
Gynecomastia, or breast enlargement and tenderness, is common during midpuberty and occurs
in up to one third of boys. It is usually temporary and disappears within 2 years. The primary
sexual characteristic in males is the development of a viable sperm. An adolescent male is
considered potentially fertile with a first ejaculation that occurs approximately 1 year after initial
testicular enlargement and the appearance of pubic hair; the ability for penile erection is present
at birth. Precocious puberty in boys may be a concern if secondary sexual characteristics occur
before the age of 9. Environmental factors, exposure to chemicals, and lifestyle changes are
sometimes thought to be the cause for the early appearance of secondary sexual characteristics in
males of certain ethnicities, as compared to non-Hispanic white males. This is not specifically
related to precocious puberty.

A student nurse is assisting with sports physicals at the local high school. Which boy in the
examples below would the student nurse notify the provider to have possible delay in puberty?
A boy who exhibits no scrotal change by age 12½
A Hispanic boy who has not had onset of Tanner 2 stage of genital development at 9.14 years
A boy who exhibits gynecomastia during midpuberty that does not disappear within 6 months
A boy who has not had complete genital growth 5 years after testicles have begun to enlarge
Rationale
A boy can be considered to have a delay in puberty if genital growth is not complete 4 years after
the testicles begin to enlarge; therefore if growth is not complete 5 years after the testicles have
begun to enlarge, the boy can be considered to have a delay in puberty. A delay in puberty is
considered if a boy has had no scrotal change by ages 13½ to 14. A boy who has not yet had
scrotal changes at 12½ cannot be considered to have delay in puberty. The onset of Tanner stage
2 of genital development occurs in Hispanic boys at age 10.04 on average. A Hispanic boy who
has not had onset of Tanner stage 2 of genital development at 9.14 years does not have a delay in
puberty. Gynecomastia or breast enlargement and tenderness is common during midpuberty in
up to one third of boys; this breast enlargement disappears in 2 years. Hence, gynecomastia in a
boy can be a sign that the boy has hit midpuberty; it is not a sign of a delay in puberty. The
disappearance of gynecomastia in 6 months is unrelated to delay in puberty.

A 17-year-old female patient tells the nurse, "I have not gotten any taller since I was 14 years of
age." What question would the nurse ask to determine if the patient has had normal physical
development?
"Could you please tell your present age?"
"Have you been taking any medications?"
"At what age did you start having menses?"
"Could you give details about your diet?"
Rationale
In adolescent females, growth in height typically ceases within 2 to 2½ years after the onset of
menarche. Therefore the nurse should ask the patient about the age at which she started her
menses. If the age at which menses started was around 11½ to 12 years, then the patient has
normal physical development. Knowing only the present age of the patient will not help the
nurse to determine whether the patient has stunted physical development. The present
medications taken by the patient are not helpful for the nurse to determine whether the patient
has stunted growth, as physical growth had ceased long ago. In this situation, knowing about the
patient's diet does not help to determine whether physical development is normal.