Test Bank for Pediatric Nursing An Introductory Text 11th edition by Debra L. Price

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Pediatric Nursing An Introductory Text 11th edition by Debra L. Price

Price: Pediatric Nursing, 11th Edition

 

Chapter 06: The Infant

 

Testbank

 

MULTIPLE CHOICE

 

  1. The nurse reminds the parent of a 2-month-old infant who is being fed through a G-button that a source of comfort for the child would be to:
a. Hold the baby in an upright position while being fed
b. Place small chips of ice in the infant’s mouth
c. Offer a pacifier frequently
d. Moisten the lips with Vaseline

 

 

ANS:   C

Sucking brings comfort and relief from tension. Because a baby being fed by artificial means will not be sucking nourishment, pacifiers provide that satisfaction.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 110              OBJ:    2

TOP:    Sucking           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. When the parent of a 3-month-old infant asks when her baby can switch from formula to cow’s milk, the nurse’s response is based on the knowledge that the child should remain on formula until:
a. 3 months of age
b. 6 months of age
c. 9 months of age
d. 12 months of age

 

 

ANS:   D

Children should not be given cow’s milk until they are 12 months of age. Breast milk and formula provide the extra nutrition needed by infants. Infants who drink cow’s milk are prone to iron-deficiency anemia, intolerance of whole milk protein, difficult metabolism for the gastrointestinal tract, and stress on the renal system.

 

DIF:    Cognitive Level: Application             REF:    p. 119              OBJ:    3

TOP:    Cow’s Milk     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse recognizes the infant’s grasp reflex when the infant’s
a. Fingers close around objects placed in the palm
b. Fingers grasp with the opposing thumb
c. Thumb and index finger grasp
d. Two hands attempt to grasp an object

 

 

ANS:   A

The grasp reflex is the tendency for the infant to close the fingers around any object placed in the palm.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 110              OBJ:    2

TOP:    Grasp Reflex                                      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse includes in the teaching plan to new parents that to stimulate the infant’s perceptual abilities the parents should:
a. Keep the nursery quiet and dimly lit to prevent overstimulation
b. Rock the child several hours a day
c. Feed the child a diet high in vitamins and protein
d. Offer a variety of sights and sounds to the infant

 

 

ANS:   D

Experiencing a variety of sights, sounds, and other stimuli helps the brain grow and perceptual abilities expand.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 111              OBJ:    5

TOP:    Topic: Growth of Perceptual Abilities

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A young mother confides in the nurse that her husband does not want her to give so much attention to their new baby for fear that the child will become spoiled. The nurse’s best response would be:
a. “Your husband is correct. Constant attention makes an infant irritable and spoiled.”
b. “Your husband is not correct. Interaction helps an infant establish trust.”
c. “Your husband is concerned for you as giving so much attention to an infant significantly depletes your energy.”
d. “Your husband knows what he is talking about. A lot of attention causes a child to become self-centered.”

 

 

ANS:   B

Parental attention and lovingly meeting the infant’s needs will generate trust in the infant. Trust is the foundation of subsequent personality development.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 110              OBJ:    5

TOP:    Development of Trust                        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse anticipates that when an infant hears a loud sudden noise, the infant will respond by:
a. Bursting into a short period of crying
b. Rapidly blinking
c. Performing the Moro reflex
d. Extending the legs

 

 

ANS:   C

The Moro reflex (startle reflex) is precipitated by a loud sudden noise. This is a simple test to confirm that the infant can hear.

 

DIF:    Cognitive Level: Application             REF:    p. 119              OBJ:    4

TOP:    Moro Reflex to Test Hearing             KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A mother complains that her 2-month-old baby doesn’t like any sort of solid food because he pushes all solid food out of his mouth. The nurse’s best response is based on the knowledge that at 2 months of age most infants:
a. Use the extrusion reflex to reject inappropriate types of food
b. Will readily eat solid food in small bites
c. Should be offered solid foods as an introduction to more mature eating
d. Suck in portions of solid food

 

 

ANS:   A

The extrusion reflex, which disappears at around the third or fourth month, causes the infant to push inappropriate food from the mouth. Feeding the 2-month-old solid food is not appropriate.

 

DIF:    Cognitive Level: Application             REF:    p. 119              OBJ:    3

TOP:    Extrusion        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The adequacy of a child’s nutritional intake can be assessed by determining if the child has gained:
a. 2 to 3 ounces per week for the first 2 months
b. 4 to 6 ounces per week for the first 6 months
c. 7 to 8 ounces per month for the first 3 months
d. Over 8 ounces per week for the first 9 months

 

 

ANS:   B

Adequacy of nutritional intake can be confirmed by the child having gained 4 to 6 ounces per week for the first 6 months.

 

DIF:    Cognitive Level: Application             REF:    p. 119              OBJ:    3

TOP:    Nutritional Adequacy                        KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse instructs the parents of a 4-month-old infant that the introduction of solid food to the baby should be initiated with:
a. Pureed fruits
b. Pureed vegetables
c. Oat-based cereal
d. Rice cereal

 

 

ANS:   D

Rice cereal should be the first solid food introduced to an infant because of its low allergy potential.

 

DIF:    Cognitive Level: Application             REF:    p. 120              OBJ:    3

TOP:    Topic: Introduction of Solid Food     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. The nurse counsels that when selecting a baby spoon the parents should select a spoon that:
a. Has a long handle
b. Has a wide body
c. Has a deep body
d. Is made of sterling silver or stainless steel

 

 

ANS:   A

The best baby spoon is one that has a long handle and a small, shallow body. The spoon can be made of any material, not necessarily sterling or stainless steel.

 

DIF:    Cognitive Level: Application             REF:    p. 120              OBJ:    3

TOP:    Choice of Baby Spoon                       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. New foods should be introduced to the infant at intervals of:
a. 1 day
b. 2 to 3 days
c. 4 to 7 days
d. 7 to 10 days

 

 

ANS:   C

New foods should be introduced to the infant at intervals of 4 to 7 days.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 120              OBJ:    3

TOP:    Solid Food      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse suggests that the progression of introduction of solid foods should be:
a. Cereal, fruits, vegetables, and meat
b. Meat, cereal, vegetables, and fruit
c. Fruit, vegetables, cereal, and meat
d. Vegetables, fruit, cereal, and meat

 

 

ANS:   A

The recommended food progression is: cereal, fruits, vegetables, and meat. Some parents prefer to offer vegetables before fruit so the infant will not develop a preference for the sweet fruit.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 120              OBJ:    3

TOP:    Solid Food      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse takes into consideration that the optimum time to initiate meat for an infant is:
a. 3 months of age
b. 4 months of age
c. 6 months of age
d. 9 months of age

 

 

ANS:   D

The recommended age for the introduction of meat to the diet of an infant is 8 to 9 months of age.

 

DIF:    Cognitive Level: Application             REF:    p. 120              OBJ:    3

TOP:    Addition of Meat                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When an 8-month-old infant refuses a new food, the best approach would be to:
a. Continue to offer food in smaller amounts
b. Sweeten the food with artificial sweetener
c. Omit the food temporarily
d. Disguise the food with cereal

 

 

ANS:   C

Omitting the food temporarily will keep mealtimes pleasant.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 121              OBJ:    3

TOP:    Refusal of Food                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse reminds the parent of a teething 5-month-old infant that to reduce the discomfort of teething the parent can:
a. Give ibuprofen dissolved in warm water
b. Give small, hard candies to relieve the discomfort
c. Rub the swollen gum with a warm washcloth
d. Provide a hard rubber teething ring

 

 

ANS:   D

A hard rubber teething ring is helpful for teething discomfort. Ibuprofen is not given to children younger than 6 months of age. Cold applications are more effective than warm ones.

 

DIF:    Cognitive Level: Application             REF:    p. 122              OBJ:    6

TOP:    Teething          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse reminds the mother who is trying to wean her baby from breastfeeding that the termination of breastfeeding should be gradual and start with the omission of:
a. The first feeding of the day
b. Any feeding the mother chooses
c. The daytime feeding
d. The nighttime feeding

 

 

ANS:   C

Cessation of breastfeeding should be gradual but should not begin with the omission of the first feeding or the nighttime feeding.

 

DIF:    Cognitive Level: Application             REF:    p. 121              OBJ:    3

TOP:    Topic: Cessation of Breastfeeding     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is aware that the first teeth to erupt in the infant are the:
a. Upper central incisors
b. Lower central incisors
c. Upper bicuspids
d. Lower bicuspids

 

 

ANS:   B

The lower central incisors are the first to erupt.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 122              OBJ:    4

TOP:    Tooth Eruption                                   KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse weighing a 6-month-old baby will be especially careful because a child of 6 months of age can:
a. Pull self to standing position
b. Roll completely over
c. Sit steadily alone
d. Crawl on the hands and knees

 

 

ANS:   B

The 6-month-old can roll completely over, making such activities as weighing a possible hazard.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 115              OBJ:    4

TOP:    Neuromuscular Development             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. When the parents of a 1-year-old tell the nurse that their baby is now walking independently, the nurse offers the anticipatory guidance suggestion to:
a. Allow the child to explore freely
b. Provide low furniture for the child
c. Cover all electrical outlets within reach of the child
d. Place the child in a walker when parents need a break

 

 

ANS:   C

Covering electrical outlets is a necessary safety precaution. Low furniture, hanging tablecloths, and drapes offer a hazard for falling and injury. A child who can walk independently needs constant supervision even if in a walker.

 

DIF:    Cognitive Level: Application             REF:    p. 118              OBJ:    4

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. The nurse recognizes a need for further instruction about interventions for colic when the parent:
a. Places the infant on a hot water bottle
b. Offers a bottle with cold water
c. Rocks the baby
d. Rubs the infant’s stomach

 

 

ANS:   B

Cold water will not help colic. Use of gentle warmth or rocking or rubbing the baby’s stomach may offer relief. Hot water bottles should not be used because of burn risk.

 

DIF:    Cognitive Level: Application             REF:    p. 122              OBJ:    9

TOP:    Colic Relief     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse instructs new parents on the safety precautions needed to protect their baby from injury. Which of the following is an appropriate recommendation?
a. Place the infant on the stomach for sleep
b. Use a firm pillow in the crib
c. Apply sunscreen before taking the baby outside
d. Use a firm, tight-fitting mattress in the crib

 

 

ANS:   D

An infant should be placed on the back for sleep. Never use a pillow in a crib. Sunscreen is not used until the baby is at least 6 months of age. The crib should have a firm, tight-fitting mattress.

 

DIF:    Cognitive Level: Application             REF:    p. 112              OBJ:    6

TOP:    Safety Issues                                      KEY:   Nursing Process Step: Evaluation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse reviewing the immunization record of a 3-month-old infant confirms that all the CDC recommended immunizations have been administered, which are:
a. DTaP, HIB, MMR, Hep A, HPV
b. Hep B, DTaP, HIB, IPV, PCV, rotavirus
c. HPV, Hep B, DTaP, MMR, varicella
d. Hep A, DTaP, MMR, HPV, rotavirus

 

 

ANS:   B

HPV, varicella, Hep A, and MMR are given when the child is older.

 

DIF:    Cognitive Level: Application             REF:    p. 118              OBJ:    6

TOP:    Immunizations                                    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. A troubled parent asks the home health nurse when discipline can be understood by the infant. The nurse bases the answer on the fact that:
a. Slapping the hands of a 2-month-old will keep the child from putting things in the mouth
b. Giving a “time out” in a crib with the bedroom door closed will keep a 6-month-old from crying for attention
c. A mild spanking will stop a 5-month-old from trying to hold on to the bottle
d. A firm “NO!” will stop a 9-month-old from pulling on a tablecloth

 

 

ANS:   D

Using a harsh voice when saying “NO!” will deter a 9-month-old from getting into harm’s way. Corporal punishment is not understood by younger children and may damage the development of trust.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 116              OBJ:    6

TOP:    Discipline        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. In planning a discussion on child safety for a group of new parents, the nurse includes information on the appropriate use of an infant car seat, which includes that the car seat should be:
a. Strapped in the back seat on the passenger side, facing forward
b. Secured in the middle of the back seat, facing the rear
c. Fastened securely in the passenger seat, facing the rear
d. Placed in the back seat on the driver’s side, facing forward

 

 

ANS:   B

The car seat should be secured with seat belts in the middle of the back seat, facing the rear.

 

DIF:    Cognitive Level: Application             REF:    p. 114              OBJ:    7

TOP:    Topic: Use of Car Seats                     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The young mother of a 9-month-old complains to the home health nurse that the partially used jars of baby food she stores in the refrigerator turn to liquid. To clarify the situation, the nurse asks:
a. “Did you heat the food in the jar in the microwave?”
b. “What brand of food are you using?”
c. “Did you carefully cap the jar?”
d. “Did you feed your baby directly from the jar?”

 

 

ANS:   D

When the child is fed directly from the jar and the jar is returned to the refrigerator, the saliva from the child digests the food in the jar, turning it to liquid.

 

DIF:    Cognitive Level: Application             REF:    p. 121              OBJ:    7

TOP:    Topic: Food in Jars                             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

COMPLETION

 

  1. The nurse is aware that a test that can be applied to children from birth to 6 years of age and measures social, motor, and language skills is the ___________.

 

ANS:

Denver II Test

The Denver II Test can measure fine- and gross-motor skills, language skills, and social skills in children from birth to 6 years of age.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 119              OBJ:    5

TOP:    Topic: Denver II Test                         KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The infant usually has his first tooth by __________ months of age.

 

ANS:

7

Tooth eruption usually starts at 7 months of age.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 122              OBJ:    6

TOP:    Teething          KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. The nurse clarifies that the disorder of paroxysmal abdominal pain is known by the more familiar name of: _________.

 

ANS:

Colic

Paroxysmal abdominal pain that disappears in children at about 3 months of age is better known as colic.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 122              OBJ:    9

TOP:    Colic               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

MULTIPLE RESPONSE

 

  1. The nurse demonstrates methods to communicate with an infant, such as: (Select all that apply.)
a. Singing
b. Talking
c. Providing a quiet, restful environment
d. Playing simple games
e. Touching

 

 

ANS:   A, B, D, E

The infant can respond to communication such as singing, touching, talking, and playing simple games.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 111              OBJ:    5

TOP:    Communication                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. As the nurse prepares anticipatory guidance information relative to nutrition for the parents of a 1-year-old, the nurse should consider: (Select all that apply.)
a. The knowledge level of the parents
b. The economic level of the parents
c. The family’s cultural practices
d. Infant development
e. The parents’ educational level

 

 

ANS:   A, C, D, E

Economy, although important, should not affect the nutritional information. All other options should be considered prior to offering information.

 

DIF:    Cognitive Level: Application             REF:    p. 119              OBJ:    3

TOP:    Teaching Plan for Nutrition               KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse instructs the parent who is initiating solid food to her infant that the first offering of solid food should: (Select all that apply.)
a. Begin with at least a full tablespoon
b. Place the food at the back of the tongue
c. Offer the food in a bottle with a large-holed nipple
d. Gradually increase the consistency of solid food
e. Dilute the food with formula

 

 

ANS:   B, D, E

Solid food should be diluted with formula and placed on the back of the baby’s tongue. The consistency of the food should be increased gradually. Solid food should never be offered in a bottle due to the danger of aspiration.

 

DIF:    Cognitive Level: Application             REF:    p. 120              OBJ:    3

TOP:    Solid Foods    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Guidelines to consider for parents who desire to make their own baby food at home are: (Select all that apply.)
a. Select fresh high-quality foods
b. Cook foods until tender
c. Cook foods in a large amount of water
d. Freeze pureed foods in a large flat pan
e. Enhance foods with honey or salt

 

 

ANS:   A, B

Fresh, high-quality foods should be cooked in a small amount of water just until the food is tender. Pureed food should be frozen in an ice cube tray and later transferred to a storage bag in the freezer. Honey, sugar, or salt should not be added.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 121              OBJ:    3

TOP:    Topic: Home Preparation                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. To avoid tooth decay in deciduous teeth, parents should: (Select all that apply.)
a. Omit intermittent night feedings
b. Avoid putting the child to bed with a bottle
c. Allow child to nurse on juice during the night
d. Substitute late-night feedings with water
e. Substitute the night feeding with a pacifier

 

 

ANS:   A, B, D

Juice or milk pool around the teeth and encourage decay.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 122              OBJ:    6

TOP:    Avoiding Tooth Decay                      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

Price: Pediatric Nursing, 11th Edition

 

Chapter 07: The Toddler

 

Testbank

 

MULTIPLE CHOICE

 

  1. When assessing an 18-month-old toddler, the nurse would expect the child to be able to:
a. Jump with both feet
b. Walk upstairs with one hand held
c. Use a vocabulary of 300 words
d. Demonstrate daytime bowel and bladder control

 

 

ANS:   B

An 18-month-old can walk upstairs if the hand is held. The child is just beginning to have physiologic control of the sphincters, but does not achieve daytime control of the bowel and bladder until later. The child cannot jump with both feet until about 30 months of age.

 

DIF:    Cognitive Level: Application             REF:    p. 125              OBJ:    2

TOP:    Summary of Toddler Growth and Development

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. At a well-child visit, a mother voices concern that her 30-month-old has a much smaller vocabulary than other children in his daycare. The nurse should:
a. Explain to the mother that the child has a significant developmental delay
b. Assess the child for other age-appropriate development
c. Suspect that the child is not getting sufficient attention from the parent
d. Suggest that the child’s hearing be evaluated

 

 

ANS:   B

No two toddlers have the same vocabulary at the same age. The nurse should assess the other developmental markers before any conclusions can be drawn. There is no sufficient evidence to support that the mother is giving the child insufficient attention or that the child has a developmental delay.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 129              OBJ:    2

TOP:    Language Development                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The parents of a hospitalized 2-year-old need to leave the unit for a couple of hours to get some sleep. The nurse should:
a. Tell the parents that one of them should remain with the child
b. Instruct the parents to leave while the baby is distracted
c. Tell the toddler that the parents are leaving, but will be back after lunch
d. Leave the toddler alone to cry himself to sleep

 

 

ANS:   C

Parents occasionally need to take a break. Do not encourage the parents to sneak out. This will damage the trust relationship and further traumatize the child. The nurse should provide comfort while the parents are gone.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 126              OBJ:    3

TOP:    Developmental Tasks                         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. At a well-child visit, the mother of a 2-year-old asks about the significance of milk in a 1000-calorie diet. The nurse informs the mother that the child needs:
a. 4 to 5 cups of milk per day
b. To substitute fruit juices for milk
c. To drink skim milk or low-fat milk
d. To drink whole milk

 

 

ANS:   C

A 2-year-old child should be switched to skim or low-fat milk to prevent weight gain. This child should have 2 cups of milk daily and 2 ounces of meat or beans.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 131              OBJ:    4

TOP:    Nutritional Counseling                       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A parent tells the nurse that his 2-year-old son does not like to eat fruit, but loves juice. The nurse advises him:
a. To give the child 10 to 12 ounces of juice per day
b. That a high intake of fruit juice can lead to diarrhea
c. That a high intake of juice will make his teeth stronger
d. To give juice before meals to stimulate the appetite

 

 

ANS:   B

A high intake of fruit juice can lead to diarrhea. Juice will also cause tooth decay. Fruit juice should be limited to 4 to 6 ounces daily. Juice will interfere with appetite for meals.

 

DIF:    Cognitive Level: Application             REF:    p. 131              OBJ:    4

TOP:    Nutrition         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A mother asks about the normal portion size for her 2 1/2-year-old daughter. The nurse explains:
a. The toddler should be allowed to eat until full
b. The toddler should eat about  to  of an adult portion
c. Offering a large portion will let the toddler exert control over intake
d. The toddler should eat small portions (1 teaspoon) on a small plate

 

 

ANS:   B

A toddler should eat about  to  of an adult portion. A large serving often overwhelms the child and can initiate eating problems for the child. Forcing a toddler to eat turns mealtime into a battlefield and should be avoided.

 

DIF:    Cognitive Level: Application             REF:    p. 131              OBJ:    4

TOP:    Nutritional Counseling                       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse taking into consideration the toileting needs of a 20-month-old toddler is aware that this age child:
a. Has voluntary control of the sphincters, but may not be ready for toilet training
b. Will be completely potty trained
c. Should be waking up dry after a night’s sleep
d. Should be waking up dry after a daytime nap

 

 

ANS:   A

The child will likely not be potty-trained. Children at this age have achieved voluntary control of the sphincters but are not usually ready to begin potty training until later. It is highly unlikely that the child wakes up dry from naps or from a night’s sleep.

 

DIF:    Cognitive Level: Application             REF:    p. 133              OBJ:    5

TOP:    Toilet Independence                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. When parents ask the nurse for advice about how to begin toilet training a 2-year-old, the nurse suggests:
a. Waiting until the child wakes up from naps dry
b. Placing the child on a potty seat for 20 minutes
c. Applying the diaper very snugly
d. Consistently using the same word for urination, (e.g., tinkle, TT)

 

 

ANS:   A

The parents should be encouraged to begin trying after the child wakes up dry from naps. This indicates that the child may be ready. Children should not be left on the potty seat for more than 10 minutes. A snug diaper and using a consistent word for urination is not useful.

 

DIF:    Cognitive Level: Application             REF:    p. 133              OBJ:    5

TOP:    Toilet Independence                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. In response to a young parent’s request for tips on selecting a daycare for her child, the nurse’s most helpful suggestion would be to:
a. Ask the faculty about their philosophy and attitudes toward children
b. Confirm that the daycare will care for the child when the child is sick
c. Consider an unlicensed facility to reduce costs
d. Select a center that cares for a large group of children

 

 

ANS:   A

The parents will want to select a daycare that shares their philosophy about child care. A daycare that cares for sick children may expose the child to an infection. An unlicensed facility may not be safe. A center with a smaller group of children is more desirable.

 

DIF:    Cognitive Level: Application             REF:    p. 135              OBJ:    6

TOP:    Daycare           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse instructing parents on home safety would stress that the most common site for accidents to toddlers is:
a. In or near the home
b. At a daycare facility
c. In a strange or new environment
d. At a playground

 

 

ANS:   A

Toddlers are most often at risk for accidents in or near the home. Although new and strange environments may cause an increased hazard, the home is still the most common site.

 

DIF:    Cognitive Level: Application             REF:    p. 136              OBJ:    8

TOP:    Injury Prevention                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. The nurse includes in the instructions pertaining to car safety that a child may be placed in a regular car seat when the child:
a. Is over 30 inches tall
b. Weighs over 40 pounds
c. Can fit the lap and shoulder seat belt
d. Is older than 4 years of age

 

 

ANS:   C

Children may ride in a regular car seat if the lap and shoulder harness fit. Age and weight are not significant if the child does not fit the seat.

 

DIF:    Cognitive Level: Application             REF:    p. 139              OBJ:    8

TOP:    Car Seats         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. To prevent falls, parents of toddlers should be encouraged to:
a. Always carry their children up and down the stairs
b. Secure the child to a changing table if leaving the child unattended
c. Leave the crib rail down so the child can climb in and out of the crib with ease
d. Lock the basement doors and use gates at the top and bottom of the stairs

 

 

ANS:   D

Children must learn to walk up and down the stairs. They should be assisted by an adult, not carried. The child should never be left unattended on a changing table. Crib rails should always be up and locked.

 

DIF:    Cognitive Level: Application             REF:    p. 140              OBJ:    8

TOP:    Injury Prevention                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. To prevent burns, parents of toddlers should be reminded to:
a. Not leave the bathroom when the hot water is running
b. Teach the child to turn on the hot water first
c. Set the hot water heater at 140°
d. Turn pot handles toward the front of the stove

 

 

ANS:   A

Parents should not leave the bathroom when the hot water is turned on (or any water is running!). The child should be taught to always turn on the cold water first. Pot handles should always be turned to the back of the stove. Hot water heaters should be set at no higher than 120°.

 

DIF:    Cognitive Level: Application             REF:    p. 140              OBJ:    8

TOP:    Injury Prevention                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. In order to protect a toddler from choking or suffocation, the nurse reminds the parents to:
a. Store small objects in a box in the playpen
b. Ensure that crib slats are more than 2 inches apart
c. Lift the child immediately out of the crib if vomiting
d. Avoid clothes with drawstrings or cords around the neck

 

 

ANS:   D

Small objects should be kept away from the toddler. Storing them in a box only works if the box is placed out of reach of the toddler. Crib slats should be less than 2 inches apart. A vomiting child should be turned on the left side. Lifting the child out could cause aspiration. Clothing should not have anything that could constrict the neck.

 

DIF:    Cognitive Level: Application             REF:    p. 140              OBJ:    8

TOP:    Choking and Suffocation                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. To prevent the threat of poisoning for the toddler, the nurse would advise:
a. Clearly labeling chemicals or harmful substances that are placed in household containers
b. Storing household cleaning supplies under the sink
c. Using child-resistant caps on medications
d. Telling the child that medicine is candy

 

 

ANS:   C

Chemicals or harmful substances should never be stored in household containers. Cleaning supplies are poisonous and should be stored on a high shelf out of reach. Child-resistant caps should be placed on all medications. Never tell a child that medicine is candy.

 

DIF:    Cognitive Level: Application             REF:    p. 138              OBJ:    8

TOP:    Poisoning        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. A parent tells the nurse that he keeps a gun in their home. In order to maintain safety, the nurse instructs the parent to:
a. Lock the loaded gun in a safe place
b. Unload and lock the gun separately from the ammunition
c. Teach the child not to touch the gun
d. Keep the loaded gun visible in order to keep an eye on it

 

 

ANS:   B

A gun should be unloaded and locked away separately from the ammunition. A toddler should never use a gun. The gun should be kept out of sight and locked as described previously.

 

DIF:    Cognitive Level: Application             REF:    p. 138              OBJ:    8

TOP:    Firearms          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. In order to help reduce the threat of a toddler drowning, the nurse can advise parents to:
a. Tell the child not to play in the water
b. Allow unsupervised playing in a shallow bath
c. Cover wading pools with a bed sheet after use
d. Supervise the child when near a water source

 

 

ANS:   D

Toddlers should never be left alone near a swimming pool or in a bathroom. Most toddlers love water and want to play in it, but they have no depth perception. Telling a toddler not to play in the water is not assurance that they will avoid the danger.

 

DIF:    Cognitive Level: Application             REF:    p. 138              OBJ:    8

TOP:    Drowning        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. Parents inquire about the correct placement of a car seat for their 15-month-old toddler who weighs 22 pounds. The nurse explains that the child should:
a. Be placed sitting forward in a safety seat
b. Be placed in a booster seat
c. Be placed in a car seat if sitting in the front seat
d. Always ride in a seat equipped with an airbag

 

 

ANS:   A

The child should be placed in a forward-facing child safety seat. The child is not old enough or big enough for a booster seat. The child should always be placed in a safety seat. The toddler should never be placed in a seat with an airbag.

 

DIF:    Cognitive Level: Application             REF:    p. 139              OBJ:    7

TOP:    Car Seats         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. The nurse stresses that car safety seats should be used:
a. Because it is mandated by law
b. Only if the parent cannot control the child
c. Only when driving on the highway
d. Until 1 year of age

 

 

ANS:   A

Car seats are mandated by law for use anytime the child is riding in the car.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 139              OBJ:    7

TOP:    Injury Prevention                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. The parents of a toddler who lives in a home with a much-loved golden retriever should be instructed to:
a. Allow the child to play freely with the pet
b. Allow the child to feed the pet
c. Teach the child that all animals are okay to pet
d. Supervise the child closely when playing with the pet

 

 

ANS:   D

A child should be supervised when playing with the pet. Toddlers do not have good coordination or judgment and can unintentionally hurt or startle an animal. The animal may bite or injure the child. Toddlers should not feed an animal or interfere with an animal while it is eating.

 

DIF:    Cognitive Level: Application             REF:    p. 138              OBJ:    8

TOP:    Animal Bites                                      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Safety and Infection Control

 

  1. When advising a parent about the appropriate length of time for a disciplinary “time out” for a 3-year-old toddler, the nurse would recommend a time of:
a. 1 minute
b. 2 minutes
c. 3 minutes
d. 4 minutes

 

 

ANS:   C

The recommended length of time for a “time out’ is 1 minute per year of the child’s age.

 

DIF:    Cognitive Level: Application             REF:    pp. 128-128     OBJ:    2

TOP:    Discipline        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse explains that physiologic anorexia is a phenomenon of the toddler that is manifested by:
a. Refusal to eat
b. Weight loss
c. Reduced appetite
d. Eating dirt or clay

 

 

ANS:   C

Physiologic anorexia is a developmental phenomenon of a reduced appetite due to decreased nutritional need because of a reduced growth rate.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 131              OBJ:    1

TOP:    Physiologic Anorexia                         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse recognizes a need for further instruction relative to supporting the development of autonomy when the parent of a 2-year-old says:
a. “My child is on a food binge. All he wants is eggs, so I fix eggs every meal.”
b. “I direct all of my child’s activities to give him security.”
c. “I ignore his tantrums for the most part. He gets over it quickly enough.”
d. “We allow many mealtime rituals like using the same cup or a certain bib.”

 

 

ANS:   B

Parents who direct all of their child’s activities diminish their sense of autonomy and development of self-confidence.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 127              OBJ:    2

TOP:    Autonomy       KEY:   Nursing Process Step: Evaluation

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. The nurse suggests the use of an “I message” when correcting a toddler, such as:
a. “I think you are a bad boy to have marked on the wall with a crayon.”
b. “I think you better give me those crayons right now.”
c. “I wish you wouldn’t make such a mess.”
d. “I feel unhappy when you mark on the wall with crayon.”

 

 

ANS:   D

The “I message” does not criticize, blame, or threaten, but identifies a feeling that the event caused. It does not demoralize the child.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 129              OBJ:    2

TOP:    I Messages      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

COMPLETION

 

  1. The nurse reminds a group of parents that no child younger than __________ years of age should be allowed to ride in a seat where there is an airbag restraint.

 

ANS:

12

Children younger than 12 years of age are at risk for injury from the deployment of an airbag.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 139              OBJ:    8

TOP:    Airbags           KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. The nurse is aware that the leading cause of death in toddlers is ___________.

 

ANS:

Accidents

Accidents are the leading cause of childhood deaths.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 136              OBJ:    8

TOP:    Accidents        KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse explains that the characteristic type of play observed in the toddler is that of __________ play.

 

ANS:

Parallel

Toddlers engage in parallel play, which is a style of play in which toddlers

enjoy playing near, but not with, other children.

 

DIF:    Cognitive Level: Application             REF:    p. 134              OBJ:    1

TOP:    Parallel Play    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The home health nurse notices that several children in the household have brown mottling on their teeth. The nurse recognizes this mottled enamel as a condition known as __________.

 

ANS:

Fluorosis

Excessive intake of fluoride will cause mottling of the enamel of children’s teeth. Use of fluoride toothpaste in a small child is frequently the cause.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 130              OBJ:    1

TOP:    Fluorosis         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse is aware that the major concern for a toddler with acetaminophen

(Tylenol) poisoning is organ damage to the __________.

 

ANS:

Liver

Acetaminophen is metabolized in the liver, therefore liver damage may occur in the event of acetaminophen poisoning.

 

DIF:    Cognitive Level: Application             REF:    p. 142              OBJ:    9

TOP:    Acetaminophen Poisoning                 KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

MULTIPLE RESPONSE

 

  1. The nurse takes into consideration that more families use the service of a daycare center because: (Select all that apply.)
a. More mothers are working
b. Mothers are returning to work sooner after childbirth
c. The cost of daycare is reasonable
d. Mothers need some free time
e. Daycare centers help a child with socialization

 

 

ANS:   A, B

Mothers are returning to work sooner after childbirth, and more mothers are working full-time or part-time. The cost of daycare is expensive. Daycare does not necessarily enhance socialization.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 135              OBJ:    6

TOP:    Need of Daycare                                KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse points out significant aspects of the shoes of a toddler, such as that the shoe should: (Select all that apply.)
a. Be one-fourth inch longer than the big toe
b. Have flexible soles
c. Fit the shape of the foot
d. Have roomy heels
e. Be checked for fit every week

 

 

ANS:   B, C

Shoes for the toddler who is walking well should be one-half inch longer than the big toe, have flexible soles, fit the shape of the foot, have a snugly fitting heel, and be checked for fit every few months.

 

DIF:    Cognitive Level: Application             REF:    p. 129              OBJ:    2

TOP:    Shoe Fit          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. In selecting a toy for a 2-year-old, the nurse would recommend such toys as: (Select all that apply.)
a. Wind-up toys
b. Toys with small parts the child can remove
c. Toy tools
d. Clay or Play-Doh
e. Push/pull toys

 

 

ANS:   C, D, E

Toy tools, clay, or push/pull toys excite the toddler’s imagination. A toddler might not be able to manipulate wind-up toys. Toys with small removable parts pose a choking hazard.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 135              OBJ:    2

TOP:    Toys                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse would anticipate that in the event that a child has swallowed a corrosive, the treatment may include: (Select all that apply.)
a. Inducing vomiting
b. Dilution with milk
c. Dilution with water
d. Administration of syrup of Ipecac
e. Tracheostomy

 

 

ANS:   B, C, E

Ingestion of corrosives may be treated by dilution with milk or water or possibly a tracheostomy if there is severe tissue damage.

 

DIF:    Cognitive Level: Application             REF:    p. 141              OBJ:    9

TOP:    Poisoning        KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Reduction of Risk