COLLEGE OF ALLIED HEALTH SCIENCES

Nursing Department
Rizal Street, Iloilo City

COMPETENCY APPRAISAL 1
Psychiatric and Pediatric Nursing
UNIT TEST 2

NAME: __________________________________________DATE: _____________ SCORE:____________

INSTRUCTION: Select the best response for each situation by shading the letter of your
choice on the answer sheet provided. Strictly, ERASURES or ALTERATIONS of any forms will
automatically invalidate your answer. HAVE FUN!

1. Which neurotransmitter has been implicated in the

development of Alzheimer’s disease? 6. Disulfiram serves as a treatment for alcoholism, it
A. Acetylcholine B. Dopamine functions to:
C. Epinephrine D. Serotonin A. lessen alcohol withdrawal symptoms
B. decrease serum alcohol levels
2. The nurse is administering a psychotropic drug to an C. restrict from alcohol drinking
elderly client who has history of benign prostatic D. treat alcohol intoxication
hypertrophy. It is most important for the nurse to
teach this client to: 7. One morning the nurse sees the client in a
A. Add fiber to his diet. depressed mood. The nurse asks her “What are you
B. Report incomplete bladder emptying. thinking about?” This communication technique is:
C. Exercise on a regular basis. A. Focusing
D. Take the prescribed dose at bedtime. B. validating.
C. reflecting.
3. The nurse is teaching a client taking a MAOI about D. giving broad opening.
foods with tyramine that he or she should avoid.
Which of the following statement indicates that the 8. Which of the following theorists believed that a
client needs further teaching? corrective interpersonal relationship with the
A. “I’m so glad I can have pizza as long as I don’t therapist was the primary mode of treatment?
order pepperoni.” A. Sigmund Freud
B. “I will be able to eat cottage cheese without B. Hildegard Peplau
worrying.” C. William Glasser
C. “I will have to avoid drinking nonalcoholic beer.” D. Harry Stack Sullivan
D. “I can eat green beans on this diet.”
9. Correcting how one thinks about the world and one-
4. A client who has been depressed and suicidal self is the focus of:
started taking a tricyclic antidepressant 2 weeks ago A. behaviorism.
and is now ready to leave the hospital to go home. B. cognitive therapy.
Which of the following is a concern for the nurse as C. Psychoanalysis
discharge plans are finalized? D. reality therapy.
A. The client may need a prescription for
diphenhydramine (Benadryl) to use for side 10. Nurse John is a aware that most crisis situations
effects. should resolve in about:
B. The nurse will evaluate the risk for suicide by A. 1 to 2 weeks
overdose of the tricyclic antidepressant.
C. The nurse will need to include teaching B. 4 to 6 weeks
regarding the signs of neuroleptic malignant
syndrome. C. 4 to 6 months
D. The client will need regular laboratory work to
monitor therapeutic drug levels. D. 6 to 12 months

11. Which factors are most essential for the nurse to

5. The nurse is caring for a client with schizophrenia
assess when providing crisis intervention foe a
who is taking haloperidol (Haldol). The client
client?
complains of restlessness, cannot sit still, and has
A. The client’s communication and coping skills.
muscle stiffness. Of the following PRN medications,
B. The client’s anxiety level and ability to express
which would the nurse administer?
feelings.
A. Haloperidol (Haldol) 5 mg PO
C. The client’s perception of the triggering event
and availability of situational supports.
B. Propranolol (Inderal) 20 mg PO D. The client’s use of reality testing and level of
C. Benztropine (Cogentin) 2 mg PO depression.
D. Trazodone 50 mg PO
 B. Memory state

12. The nurse considers a client’s response to crisis C. Delusional system

intervention successful if the client:
A. changes coping skills and behavioral D. Creativity level
patterns.
B. develops insight into reasons why the crisis 17. Psychotherapeutic treatment modalities were
occurred. created and developed based on their existing
C. learns to relate better to others. theories. Modern therapies such as cognitive
D. returns to his previous level of functioning. and reality therapies were based on existential
theories which aim to:
13. Nurse Monette recognizes that the focus of A. Enhance patient’s self-awareness
environmental (MILIEU) therapy is to:
A. manipulate the environment to bring about B. Overcome fears and anxiety
positive changes in behavior. C. Develop patient’s insight
D. Explore solutions to patient’s identified
B. allow the client’s freedom to determine problems
whether or not they will be involved in
activities. 18. Peplau has identified several sub roles of the
psychiatric nurse. When the nurse utilizes
C. role play life events to meet individual interpersonal techniques to help the patient
needs. adapt or cope with life experiences, he/she
function as a:
D. use natural remedies rather than drugs to A. counselor.
control behavior. B. therapist.
C. surrogate.
14. Nurse Sarah ensures a therapeutic environment D. teacher.
for all clients. Which of the following best
describes a therapeutic milieu? 19. Older adults have reached Erikson's
A. A therapy that rewards adaptive behavior developmental stage of ego integrity, when
they:
B. A living, learning or working environment.
A. acknowledge that one cannot get
C. A cognitive approach to change behavior everything one wants in life.
B. assess their lives and identify actions that
D. A permissive and congenial environment had value and purpose.
C. express a wish that life could be relived
15. Joy who has just experienced her second differently.
spontaneous abortion expresses anger towards D. feel that they are being punished for things
her physician, the hospital and the “rotten they did not do.
nursing care”. When assessing the situation,
the nurse recognizes that the client may be 20. The superego is that part of the psyche that:
using the coping mechanism of: A. uses defensive function for protection.
A. Projection B. determines the circumstances before
making decisions.
B. Displacement C. is impulsive and without morals.
D. the censoring portion of the mind.
C. Denial
21. The ego's role is to
D. Reaction formation A. alleviate hysteria
B. suppress the conscience
C. mediate between the id and superego
D. counteract the superego
16. When nurse Hazel considers a client’s
E. counteract the id
placement on the continuum of anxiety, a key in
determining the degree of anxiety being
22. Liza says, “Give me 10 minutes to recall the
experienced is the client’s:
name of our college professor who failed many
A. Perceptual field
 students in our anatomy class.” She is B. “What would you like to do now that you’re
operating on her: about to go home?”
A. subconscious. C. “You seem to have concerns about going
B. conscious. home.”
C. unconscious. D. “Aren’t you glad that you’re going home soon?”
D. ego.
28. There are various conditions the nurse must
23. A person who failed a class but tells people he meet to establish a therapeutic relationship with
got an A is experiencing denial. Why is this an the client. Congruence between what is felt and
unproductive way of dealing with what is being expressed is a display of the
disappointment? nurse’s:
A. Denial is unproductive because it is a A. trust.
refusal to accept reality. B. respect.
B. Denial is unproductive because it places C. genuineness.
blame for the problem on someone else. D. empathy.
C. Denial is unproductive because it creates a
solution to a problem that does not exist. 29. Therapeutic communication is the key to
D. Denial is unproductive because the problem enhancing the nurse-client relationship. The
is not discussed at all. nurse’s statement: “I understand that this must
be a tough time for you” reflects:
24. A runner who trains twice as hard after suffering A. concern
a big loss in a race is experiencing _____. B. transference
A. sublimation. C. respect
B. displacement. D. empathy
C. denial.
D. repression 30. The therapeutic relationship has different
phases that overlap and interlock. Planning for
25. Mr. Garcia, an attorney who throws books and termination of the relationship occurs during
furniture around the office after losing a case is what phase?
referred to the psychiatric nurse in the law firm’s A. preorientation
employee assistance program. Nurse Beatriz B. orientation
knows that the client’s behavior most likely C. working
represents the use of which defense D. termination
mechanism?
A. Regression 31. The nurse asks a client to roll up his sleeves so
B. Projection she can take his blood pressure. The client
C. Reaction-formation replies “If you want I can go naked for you.” The
D. Intellectualization most therapeutic response by the nurse is:
A. “You’re attractive but I’m not interested.”
26. A client is displaying reaction formation when: B. “You wouldn’t be the first that I will see
A. he substitutes an activity for one that is truly naked.”
desired. C. “I will report you to the guard if you don’t
B. he redirects sexual drives into socially control yourself.”
acceptable channels. D. “I only need access to your arm. Putting up
C. he transforms mental conflict into a physical your sleeve is fine.”
symptom.
D. he’s consciously exhibiting behavior that is 32. Nurse Myrna develops a counter-transference
at the exact opposite of an unconscious reaction. This is evidenced by:
feeling. A. Revealing personal information to the client.

27. The client is concerned about his coming B. Focusing on the feelings of the client.
discharge, manifested by being unusually sad.
Which is the most therapeutic approach by the C. Confronting the client about discrepancies
nurse? in verbal or non-verbal Behavior.
A. “You are much better than when you were
admitted so there’s no reason to worry.” D. The client feels angry towards the nurse
who resembles his mother.
 relationship occurs. After 3 months of
interaction with her patient, Nurse Clara
33. Anthony is very hostile toward one of the staff observes that he is making passes at her. One
for no apparent reason. He is manifesting: time, the patient held her hand and confessed
his feelings for her. What would be Nurse
A. Splitting Clara’s most appropriate response?
B. Transference A. “I am sorry but I don’t like you.”
C. Countertransference B. “If you’ll get better, I’ll think about it.”
D. Resistance C. “It would be best if we’ll just remain friends.”

D. “Our nurse-patient relationship is strictly

professional.”
34. A client with obsessive-compulsive disorder is
hospitalized on an inpatient unit. Which nursing
response is most therapeutic?
37. While on duty in the ER, Nurse Pharlynis
A. Accepting the client’s obsessive-compulsive assessing a female patient to obtain subjective
behaviors information concerning the client’s sexual and
reproductive status. The client tells her: “I don’t
B. Challenging the client’s obsessive- want to talk about that. It’s private and personal”
compulsive behaviors Which of the following will be the most
therapeutic response nurse Pharlyn can make?
C. Preventing the client’s obsessive-
compulsive behaviors A. “I hate being asked these questions too.”
D. Rejecting the client’s obsessive-compulsive B. “I am a professional nurse, and as such I’ll
behaviors have you know that all data will be kept
confidential.”

C. “I know that some of these questions are

35. Maladaptive behaviors are common responses
difficult for you, but as a professional nurse,
to patients to overcome severe anxiety and
I must legally respect your confidentiality.”
stress in the medical-surgical setting. The nurse
should know how best to handle such D. “This is difficult for you to speak about, but I
situations. Mr. Ata Pees, a COPD patient, keeps am trying to perform a complete
calling the nurse every 10 minutes to have his assessment and I need this information.”
VS checked and insists that she stay with him
until his relatives arrive. The most therapeutic
response of the nurse would be:
38. Nurse Rinoa is the nurse attending to a client
A. “I have other patients to attend to. I can only with a clinical diagnosis of major depression
check on you every 30 minutes.” who had a history of attempted suicide. The
patient tells the nurse: “I should have died a
B. “I’m sorry to have kept you waiting. There long time ago. I have always been a failure.
was an emergency I have to attend to.” Nothing ever goes right for me.” The most
therapeutic response nurse Rinoa may make to
C. “You’re perfectly fine, Mr. Bo Ang. Why do
her client is:
you have to call on me often?”
A. “I do not see you as a loser.”
D. “If you call on me again after 10 minutes, I
just have to ignore you.”
B. “You have everything to live for.”

36. The nurse has power over the client by virtue of C. “Feeling like this is all part of your
his or her professional role. That power can be illness.”
abused if excessive familiarity or an intimate
 D. “You’ve been feeling like a failure for a 44. When the client says, “I met Joe at the dance
while?” last week,” what is the best way for the nurse to
ask the client to describe her relationship with
39. Client: “I had and accident.” Joe?
Nurse: “Tell me about your accident.” A. “Joe who?”
B. “Tell me about you and Joe.”
This is an example of which therapeutic C. “Tell me about Joe.”
communication technique? D. “Joe, you mean that blond guy with the dark
A. Making observations blue eyes?”
B. Offering self
C. General leads 45. Which of the following is a concrete message?
D. Reflection A. “Help me put this pile of books on Marsha’s
desk.”
40. “Earlier today you said you were concerned that B. “When is she coming home?”
your son was still upset with you. When I C. “Get this out of here.”
stopped by your room an hour ago, you and D. “They said it is too early to get in.”
your son seemed relaxed and smiling as you
spoke to each other. How did things go between 46. Which of the following are examples of a
the two of you?” therapeutic communication response? Select all
A. Consensual validation that apply:
B. Accepting i. “Don’t worry – everybody has a bad day
C. Encouraging comparison occasionally.”
D. General leads ii. “Tell me more about your discharge
plans.”
41. “Why do you always complain about the night iii. “That sounds like a great idea.”
nurse? She is a nice woman and a fine nurse iv. “What might you do the next time you’re
and has five kids to support. You’re wrong when feeling angry?”
you say she is noisy and uncaring.” v. “I don’t think your mother will appreciate
that behavior.”
This example reflects which non-therapeutic A. i, ii, iii
technique? B. ii, iii, iv
A. Requesting an explanation C. iii, iv, v
B. Defending D. i, ii, iii, iv, v
C. Disagreeing
D. Advising 47. The nurse observes a client pacing in the hall.
Which statement by the nurse may help the
42. “How does Jerry make you upset?” is a non- client recognize his anxiety?
therapeutic communication technique because A. “I guess you’re worried about something,
it aren’t you?”
A. gives a literal response. B. “Can I get you some medication to help
B. interprets what the client is saying. calm you?”
C. indicates an external source of the emotion. C. “Have you been pacing for a long time?”
D. is just another stereotyped comment. D. “I notice that you’re pacing. How are you
feeling?”
43. Client: “I was so upset about my sister ignoring
my pain when I broke my leg.” Situation: An old woman was brought for evaluation
Nurse: “When are you going to your next due to the hospital for evaluation due to increasing
diabetes education program?” forgetfulness and limitations in daily function.

This is a non-therapeutic response because the 48. She tearfully tells the nurse “I can’t take it when
nurse has: she accuses me of stealing her things.” Which
A. used testing to evaluate the client’s insight. response by the nurse will be most therapeutic?
B. exhibited an egocentric focus. A. ”Don’t take it personally. Your mother does
C. changed the topic. not mean it.”
D. advised the client what to do. B. “Have you tried discussing this with your
mother?”
 C. “This must be difficult for you and your a. Saying “dada” and “mama” specifically
mother.” (“dada” to father and “mama” to
D. “Next time ask your mother where her mother).
things were last seen.” b. Saying three other words besides
“mama” and “dada.”
49. Nina reveals that the boyfriend has been c. Saying “dada” and “mama”
pressuring her to engage in premarital sex. The nonspecifically.
most therapeutic response by the nurse is: d. Saying “ball” when parents point to a
A. “I can refer you to a spiritual counselor if ball.
you like.”
B. “I can refer you to your parents if you like.”
C. “It sounds like this problem is related to
your paralysis.”
D. “How do you feel about being pressured
into sex by your boyfriend?”
54. Which of the following, if described by the
Situation: An old woman was brought for evaluation parents of a child with cystic fibrosis (CF),
due to the hospital for evaluation due to increasing indicates that the parents understand the
forgetfulness and limitations in daily function. underlying problem of the disease?
a. An abnormality in the body's mucus-
50. She says to the nurse who offers her breakfast, secreting glands.
“Oh no, I will wait for my husband. We will eat b. Formation of fibrous cysts in various
together” The therapeutic response by the body organs.
nurse is: c. Failure of the pancreatic ducts to
A. “Your husband is dead. Let me serve you develop properly.
your breakfast.” d. Reaction to the formation of antibodies
B. “I’ve told you several times that he is dead. against streptococcus.
It’s time to eat.”
C. “You’re going to have to wait a long time, 55. When developing the plan of care for a child
because his dead already.” with cystic fibrosis (CF) who is scheduled to
D. “What made you say that your husband is receive postural drainage, the nurse should
alive? anticipate performing postural drainage at which
of the following times?
51. The mother asks the nurse for advice about a. After meals.
discipline for her 3-year-old. Which of the b. Before meals.
following should the nurse suggest that the c. After rest periods.
mother use? d. Before inhalation treatments.
a. Structured interactions.
b. Spanking. 56. The parent of an infant with a cleft lip and palate
c. Reasoning. asks the nurse when the infant's cleft palate will
d. Time-out. be repaired. The nurse responds by stating that
the first repair of a cleft palate is usually done at
52. After teaching the parents of a toddler about which of the following times?
commonly aspirated foods, which of the a. Before the eruption of teeth.
following foods, if identified by the parents as b. When the child weighs approximately
easily aspirated, would indicate the need for 10 kg (22 lb).
additional teaching? c. Before the development of speech.
a. Popcorn. d. After the child learns to drink from a
b. Raw vegetables. cup.
c. Round candy. 57. After teaching the parents of an infant
d. Crackers. diagnosed with Hirschsprung's disease, the
nurse determines that the parents understand
53. Which of the following is appropriate language the diagnosis when the father states which of
development for an 8-month-old? The child the following?
should be: a. “There is no rectal opening for stool to
pass.”
 b. “There is a tube between the trachea The nurse should explain to the parents that
and esophagus.” toddlers use ritualistic patterns to:
c. “The nerves at the end of the large a. Establish a sense of identity.
colon are missing.” b. Establish control over adults in their
d. “The muscle below the stomach is too environment.
tight.” c. Establish sequenced patterns of
learning behavior.
58. A child diagnosed with tetralogy of Fallot d. Establish a sense of security.”
becomes upset, crying and thrashing around
when a blood specimen is obtained. The child's 63. The mother of a 4-year-old expresses concern
color becomes blue and the respiratory rate that her child may be hyperactive. She
increases to 44 breaths/min. Which of the describes the child as always in motion,
following actions should the nurse do first? constantly dropping and spilling things. Which
a. Obtain a prescription for sedation for of the following actions would be appropriate at
the child. this time?
b. Assess for an irregular heart rate and a. Determine whether there have been
rhythm. any changes at home.
c. Explain to the child that it will only hurt b. Explain that this is not unusual
for a short time. behavior.
d. Place the child in a knee-to-chest c. Explore the possibility that the child is
position. being abused.
d. Suggest that the child be seen by a
59. The parents of a 3-week-old healthy newborn pediatric neurologist.
ask the nurse why their daughter is
intermittently cross-eyed. The nurse's best
response is: 64. An adolescent tells the school nurse that she
a. “An eye patch may be necessary for 6 would like to use tampons during her period.
weeks to correct her vision.” The nurse should first:
b. “Your daughter will likely need an a. Assess her usual menstrual flow
ophthalmology consult.” pattern.
c. “It is normal to have eye-crossing in the b. Determine whether she is sexually
newborn period.” active.
d. “Surgery may be necessary to correct c. Provide information about preventing
your daughter’s vision.” toxic shock syndrome.
d. Refer her to a specialist in adolescent
60. An 11-year-old is admitted for treatment of an gynecology.
asthma attack. Which of the following indicates
immediate intervention is needed? 65. A nurse is assessing the growth and
a. Thin, copious mucous secretions. development of a 14-year-old boy. He reports
b. Productive cough. that his 13-year-old sister is 2 inches taller than
c. Intercostal retractions. he is. The nurse should advise the boy that the
d. Respiratory rate of 20 breaths/minute. growth spurt in adolescent boys, compared with
the growth spurt of adolescent girls:
61. A mother states that she thinks her 9-month-old a. Occurs at the same time.
“is developing slowly.” When assessing the b. Occurs 2 years earlier.
infant's development, the nurse is also c. Occurs 2 years later.
concerned because the infant should be d. Occurs 1 year earlier.
demonstrating which of the following
characteristics? 66. A parent asks the nurse about head lice
a. Vocalizing single syllables. (pediculosis capitis) infestation during a visit to
b. Standing alone. the clinic. Which of the following symptoms
c. Building a tower of two cubes. should the nurse tell the parent is most common
d. Drinking from a cup with little spilling. in a child infected with head lice?
a. Itching of the scalp.
62. A 2-year-old always puts his teddy bear at the b. Scaling of the scalp.
head of his bed before he goes to sleep. The c. Serous weeping on the scalp surface.
parents ask the nurse if this behavior is normal.
 d. Pinpoint hemorrhagic spots on the 72. A child with cystic fibrosis is receiving
scalp surface. gentamicin. Which of the following nursing
actions is most important?
67. A mother asks the nurse, “How did my children a. Monitoring intake and output.
get pinworms?” The nurse explains that b. Obtaining daily weights.
pinworms are most commonly spread by which c. Monitoring the client for indications of
of the following when contaminated? constipation.
a. Food. d. Obtaining stool samples for hemoccult
b. Hands. testing.
c. Animals.
d. Toilet seats. 73. At a follow-up appointment after being
hospitalized, an adolescent with a history of
68. After teaching a group of parents about temper cystic fibrosis (CF) describes his stools to the
tantrums, the nurse knows the teaching has nurse. Which of the following descriptions
been effective when one of the parents states should the nurse interpret as indicative of
which of the following? continued problems with malabsorption?
a. “I will ignore the temper tantrum.” a. Soft with little odor.
b. “I should pick up the child during the b. Large and foul-smelling.
tantrum.” c. Loose with bits of food.
c. “I'll talk to my daughter during the d. Hard with streaks of blood.
tantrum.”
d. “I should put my child in time-out.”

69. The nurse discusses the eating habits of 74. Which one of the following children is at most
school-age children with their parents, risk for sudden infant death syndrome (SIDS)?
explaining that these habits are most influenced a. Infant who is 3 months old.
by: b. 2-year-old who has apnea lasting up to
a. Food preferences of their peers. 5 seconds.
b. Smell and appearance of foods offered. c. First-born child whose parents are in
c. Examples provided by parents at their early forties.
mealtimes. d. 6-month-old who has had two bouts of
d. Parental encouragement to eat pneumonia.
nutritious foods.
75. When developing the ongoing plan of care for
70. A mother has heard that several children have the parents whose infant died of sudden infant
been diagnosed with mononucleosis. She asks death syndrome (SIDS), the nurse should plan
the nurse what precautions should be taken to to accomplish which of the following on the
prevent this from occurring in her child. The second home visit?
nurse should instruct the mother to: a. Allow the parents to express their
a. Take no particular precautionary feelings.
measures. b. Have the parents gain an
b. Sterilize the child's eating utensils understanding of the disease.
before they are reused. c. Assess the impact of the infant's death
c. Wash the child's linens separately in on their other children.
hot, soapy water. d. Deal with issues such as having other
d. Wear masks when providing direct children.
personal care.
76. A 3-year-old is brought into the emergency
71. A father asks the nurse how he would know if department in her mother's arms. The child's
his child had developed mononucleosis. The mouth is open and she is drooling and lethargic.
nurse explains that in addition to fatigue, which Her mother states that she became ill suddenly
of the following would be most common? within the past 2 hours. What should the nurse
a. Liver tenderness. do first?
b. Enlarged lymph glands. a. Draw blood cultures for complete blood
c. Persistent nonproductive cough. count.
d. A blush-like generalized skin rash. b. Start an intravenous line.
 c. Inspect the child's throat with a tongue d. Request a prescription for medication to
blade. treat the elevated temperature.
d. Maintain the child in an undisturbed,
upright position. 81. A nurse is planning care for a 12-year-old with
rheumatic fever. The nurse should teach the
77. The father of a 16-month-old child calls the parents to:
clinic because the child has a low-grade fever, a. Observe the child closely.
cold symptoms, and a hoarse cough. Which of b. Allow the child to participate in activities
the following should the nurse suggest that the that will not tire him.
father do? c. Provide for adequate periods of rest
a. Offer extra fluids frequently. between activities.
b. Bring the child to the clinic immediately. d. Encourage someone in the family to be
c. Count the child's respiratory rate. with the child 24 hours a day.
d. Use a hot air vaporizer.
82. A 14-year-old girl with sickle cell disease has
78. A father brings his 3-month-old infant to the her fourth hospitalization for sickle cell crisis.
clinic, reporting that the infant has a cold, is Her family is planning a ski vacation in the
having trouble breathing, and “just doesn't seem mountains. What should the nurse tell the
to be acting right.” Which of the following parents?
actions should the nurse do first? a. Encourage them to go on the trip.
a. 1.Check the infant's heart rate. b. Go on the trip, but find a sitter for the
b. 2.Weigh the infant. 14-year-old.
c. 3.Assess the infant's oxygen saturation. c. Suggest the trip be postponed until next
d. 4.Obtain more information from the year.
father. d. Explain that the high altitude may cause
a crisis.
79. In preparation for discharge, the nurse teaches
the mother of an infant diagnosed with 83. The nurse explains to the parents of a 1-year-
bronchiolitis about the condition and its old child admitted to the hospital in sickle cell
treatment. Which of the following statements by crisis that the local tissue damage the child has
the mother indicates successful teaching? on admission is caused by which of the
a. 1.“I need to be sure to take my child's following?
temperature every day.” a. Autoimmune reaction complicated by
b. 2.“I hope I don't get a cold from my hypoxia.
child.” b. Lack of oxygen in the red blood cells.
c. 3.“Next time my child gets a cold I need c. Obstruction to circulation.
to listen to the chest.” d. Elevated serum bilirubin concentration.
d. 4.“I need to wash my hands more
often.” 84. A mother asks the nurse if her child's iron
deficiency anemia is related to the child's
frequent infections. The nurse responds based
on the understanding of which of the following?
a. Little is known about iron deficiency
anemia and its relationship to infection
in children.
b. Children with iron deficiency anemia are
80. A 13-year-old has been admitted with a more susceptible to infection than are
diagnosis of rheumatic fever and is on bed rest. other children.
He has a sore throat. His joints are painful and c. Children with iron deficiency anemia are
swollen. He has a red rash on his trunk and is less susceptible to infection than are
experiencing aimless movements of his other children.
extremities. Use the chart below to determine d. Children with iron deficiency anemia are
what the nurse should do first. equally as susceptible to infection as
a. Report the heart rate to the primary are other children.
health care provider.
b. Apply lotion to the rash.
c. Splint the joints to relieve the pain.
85. Which of the following foods should the nurse d. A fontanel that bulges with crying.
encourage the mother to offer to her child with
iron deficiency anemia? 90. Before placement of a ventriculoperitoneal
a. Rice cereal, whole milk, and yellow shunt for hydrocephalus, an infant is irritable,
vegetables. lethargic, and difficult to feed. To maintain the
b. Potato, peas, and chicken. infant's nutritional status, which of the following
c. Macaroni, cheese, and ham. actions would be most appropriate?
d. Pudding, green vegetables, and rice. a. Feeding the infant just before doing any
procedures.
b. Giving the infant small, frequent
feedings.
c. Feeding the infant in a horizontal
86. A diagnosis of hemophilia A is confirmed in an position.
infant. Which of the following instructions should d. Scheduling the feedings for every 6
the nurse provide the parents as the infant hours.
becomes more mobile and starts to crawl?
a. Administer one-half of a children's 91. A 4-year-old child with hydrocephalus is
aspirin for a temperature higher than scheduled to have a ventroperitoneal shunt in
101°F (38.3°C). the right side of the head. When developing the
b. Sew thick padding into the elbows and child's postoperative plan of care, the nurse
knees of the child's clothing. should place the preschooler in which of the
c. Check the color of the child's urine following positions immediately after surgery?
every day. a. On the right side, with the foot of the
d. Expect the eruption of the primary teeth bed elevated.
to produce moderate to severe b. On the left side, with the head of the
bleeding. bed elevated.
c. Prone, with the head of the bed
87. A child with hemophilia presents with a burning elevated.
sensation in the knee and reluctance to move d. Supine, with the head of the bed flat.
the body part. The nurse collaborates with the
care team to provide factor replacement and:
a. Administer an aspirin-containing
compound.
b. Institute rest, ice, compression, and
elevation (RICE).
c. Begin physical therapy with active
range of motion. 92. The mother of a 17-year-old girl with Down
d. Initiate skin traction. syndrome tells the nurse that her daughter
recently stated that she has a boyfriend. The
88. When positioning a neonate with an unrepaired mother is concerned that her daughter might
myelomeningocele, which of the following become pregnant. Which of the following is the
positions is most appropriate? most appropriate suggestion made by the
a. Supine with the hips at 90-degree nurse?
flexion. a. “I understand your concern; you may
b. Right side-lying position with the knees want to start your daughter on a birth
flexed. control pill.”
c. Prone with hips in abduction. b. “Women with Down syndrome are
d. Supine in semi-Fowler's position with infertile so you don't need to worry
chest and abdomen elevated. about her getting pregnant.”
c. “I understand your concern; you may
89. The nurse reports to the primary health care want to enroll your daughter in an
provider signs of increased intracranial pressure abstinence program.”
in an infant with a myelomeningocele who has d. “I know it may be difficult, but you may
which of the following? want to suggest that your daughter
a. Minimal lower-extremity movement. break off the relationship.”
b. A high-pitched cry.
c. Overflow voiding only.
93. The nurse discusses with the parents how best
to raise the IQ of their child with Down
syndrome. Which of the following would be 97. “The primary care provider is able to reduce an
most appropriate? infant's hernia and schedules the infant for a
a. Serving hearty, nutritious meals. herniorrhaphy in 2 days. The mother asks the
b. Giving vasodilator medications as nurse why the surgery is not performed now.
prescribed. Which of the following responses indicates that
c. Letting the child play with more able the nurse understands the rationale for delaying
children. the surgery?
d. Providing stimulating, nonthreatening a. “Delaying the surgery ensures that your
life experiences. infant will receive the proper
preoperative preparation.”
94. A 3-month-old infant with meningococcal b. “We need to make sure that your infant
meningitis has just been admitted to the receives nothing by mouth for at least
pediatric unit. Which nursing intervention has 24 hours before the surgery.”
the highest priority? c. “Waiting these 2 days helps to allow
a. Instituting droplet precautions. any edema and inflammation in the
b. Administering acetaminophen (Tylenol). area to subside.”
c. Obtaining history information from the d. “Your infant needs to wear a truss for at
parents. least 24 hours before any surgery can
d. Orienting the parents to the pediatric be attempted.”
unit.
98. Which of the following would be most
95. Which sign should lead the nurse to suspect appropriate for the nurse to teach the mother of
that a child with meningitis has developed a 6-month-old infant hospitalized with severe
disseminated intravascular coagulation? diarrhea to help her comfort her infant who is
a. Hemorrhagic skin rash. fussy?
b. Edema. a. Offering a pacifier.
c. Cyanosis. b. Placing a mobile above the crib.
d. Dyspnea on exertion. c. Sitting at crib side talking to the infant.
d. Turning the television on to cartoons.
96. When assessing an infant with suspected
inguinal hernia, which of the following findings 99. A child is started on a soft diet after having been
would be most significant? on clear liquids following an episode of severe
a. The inguinal swelling is reddened, and gastroenteritis. When helping the mother
the abdomen is distended. choose foods for her child, which of the
b. The infant is irritable, and a thickened following foods would be most appropriate?
spermatic cord is palpable. a. Muffins and eggs.
c. The inguinal swelling can be reduced, b. Bananas and rice cereal.
and the infant has a stool in the diaper. c. Bran cereal and a bagel.
d. The infant's diaper is wet with urine, d. Pancakes and sausage.
and the abdomen is nontender.

100. A toddler is brought to the emergency room

after ingesting an undetermined amount of drain
cleaner. The nurse should expect to assist with
which of the following first?
a. Administering an emetic.
b. Performing a tracheostomy.
c. Performing gastric lavage.
d. Inserting an indwelling urinary (Foley)
catheter.