The student nurse is assigned to take the vital signs of the clients in
the pediatric ward. The student nurse reports to the staff nurse that
the parent of a toddler who is 2 days postoperative after a cleft palate
repair has given the toddler a pacifier. What would be the best
immediate action of the nurse?
C. Discuss this action with the parents
Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.
MThe nurse is providing a health teaching to the mother of an 8-year-old
child with cystic
fibrosis. Which of the following statement if made by the mother
would indicate to the nurse the need for further teaching about the
medication regimen of the child?
D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.
AThe mother brought her child to the clinic for follow-up check up. The
mother tells the nurse that 14 days after starting an oral iron
supplement, her child’s stools are black. Which of the following is the
best nursing response to the mother?
B. “This is a normal side effect and means the medication is working”
When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.
An 8-year-old boy with asthma is brought to the clinic for check up.
The mother asks the nurse if the treatment given to her son is
effective. What would be the appropriate response of the nurse?
C. I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer
Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.
The nurse is caring to a child client who is receiving tetracycline.
The nurse is aware that in taking this medication, it is very important
D. Keep the child out of the sunlight
Tetracycline may cause a phototoxic reaction.
A 14 day-old infant with a cyanotic heart defects and mild congestive
heart failure is brought to the emergency department. During
assessment, the nurse checks the apical pulse rate of the infant. The
apical pulse rate is 130 beats per minute. Which of the following is
the appropriate nursing action?
D. Administer the medication as scheduled
The normal heart rate of an infant is 120-160 beats per minute.
The physician prescribed gentamicin (Garamycin) to a child who is also
receiving chemotherapy. Before administering the drug, the nurse should
check the results of the child’s:
C. Renal Function tests
Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.
Which of the following is the suited size of the needle would the nurse
select to administer the IM injection to a preschool child?
C. 21 G, 1 inch
In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.
A 9-year-old boy is admitted to the hospital. The boy is being treated
with salicylates for the migratory polyarthritis accompanying the
diagnosis of rheumatic fever. Which of the following activities
performed by the child would give a best sign that the medication is
C. Playing mini piano
The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.
The physician decided to schedule the 4-year-old client for repair of
left undescended testicle. The Injection of a hormone, HCG finds it
less successful for treatment. To administer a pentobarbital sodium
(Nembutal) suppository preoperatively to this client, in which position
should the nurse place him?
D. Side-lying with upper leg flexed
The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.
The nurse is caring to a 24-month-old child diagnosed with congenital
heart defect. The physician prescribed digoxin (Lanoxin) to the
client. Before the administration of the drug, the nurse checks the
apical pulse rate to be 110 beats per minute and regular. What would be
the next nursing action?
C. Give the digoxin as prescribed
For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).
An 8-year-old client with cystic fibrosis is admitted to the hospital
and will undergo a chest physiotherapy treatment. The therapy should be
properly coordinated by the nurse with the respiratory therapy
department so that treatments occur during:
B. Between meals
Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.
The nurse is providing health teaching about the breastfeeding and
family planning to the client who gave birth to a healthy baby girl.
Which of the following statement would alert the nurse that the client
needs further teaching?
C. “I may not have periods while I am breastfeeding, so I don’t need family planning”
It is common misconception that breastfeeding may prevent pregnancy.
A toddler is brought to the hospital because of severe diarrhea and
vomiting. The nurse assigned to the client enters the client’s room and
finds out that the client is using a soiled blanket brought in from
home. The nurse attempts to remove the blanket and replace it with a
new and clean blanket. The toddler refuses to give the soiled blanket.
The nurse realizes that the best explanation for the toddler’s behavior
B. The blanket is an important transitional object
The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.
The nurse has knowledge about the developmental task of the child. In
caring a 3-year-old-client, the nurse knows that the suited
developmental task of this child is to:
D. Explore and manipulate the environment
Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.
A mother who gave birth to her second daughter is so concerned about her
2-year old daughter. She tells the nurse, “I am afraid that my
2-year-old daughter may not accept her newly born sister”. It is
appropriate to the nurse to response that:
D. The mother spend time alone with her older daughter when the baby is sleeping
The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.
A 2-year-old client with cystic fibrosis is confined to bed and is not
allowed to go to the playroom. Which of the following is an appropriate
toy would the nurse select for the child:
D. Pounding board and hammer
The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.
Which of the following clients is at high risk for developmental
D. A 2 1/2 –year old boy with cystic fibrosis
It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.
Which of the following would be the best divesionary activity for the
nurse to select for a 2 weeks hospitalized 3-year-old girl?
C. xylophone toy
The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.
A nurse is providing safety instructions to the parents of the
11-month-old child. Which of the following will the nurse includes in
B. Installing a gate at the top and bottom of any stairs in the home
An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.
An 8-year-old girl is in second grade and the parents decided to enroll
her to a new school. While the child is focusing on adjusting to new
environment and peers, her grades suffer. The child’s father severely
punishes the child and forces her daughter to study after school. The
father does not allow also her daughter to play with other children.
These data indicate to the nurse that this child is deprived of forming
which normal phase of development?
D. Close relationship with peers
In second grade a child needs to form a close relationships with peers.
A 5-year-old boy client is scheduled for hernia surgery. The nurse is
preparing to do preoperative teaching with the child. The nurse should
knows that the 5-year-old would:
B. Asks many questions regarding the condition and the procedure
A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.
The nine-year-old client is admitted in the hospital for almost 1 week
and is on bed rest. The child complains of being bored and it seems
tiresome to stay on bed and doing nothing. What activity selected by
the nurse would the child most likely find stimulating?
C. Assembling handouts with the nurse for an upcoming staff development meeting
A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.
The parent of a 16-year-old boy tells the nurse that his son is driving a
motorbike very fast and with one hand. “It is making me crazy!” What
would be the best explanation of the nurse to the behavior of the boy?
B. The adolescent feels indestructible
Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
An 8-month-old infant is admitted to the hospital due to diarrhea. The
nurse caring for the client tells the mother to stay beside the infant
while making assessment. Which of the following developmental
milestones the infant has reached?
D. Recognizes but is fearful of strangers
An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.
The community nurse is conducting a health teaching in the group of
married women. When teaching a woman about fertility awareness, the
nurse should emphasize that the basal body temperature:
A. Should be recorded each morning before any activity
The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
The community nurse is providing an instruction to the clients in the
health center about the use of diaphragm for family planning. To
evaluate the understanding of the woman, the nurse asks her to
demonstrate the use of the diaphragm. Which of following statement
indicates a need for further health teaching?
C. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.
The client visits the clinic for prenatal check-up. While waiting for
the physician, the nurse decided to conduct health teaching to the
client. The nurse informed the client that primigravida mother should
go to the hospital when which patter is evident?
D. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.
A nurse is planning a home visit program to a new mother who is 2 weeks
postpartum and breastfeeding, the nurse includes in her health teaching
about the resumption of fertility, contraception and sexual activity.
Which of the following statement indicates that the mother has
understood the teaching?
B. “Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal lubricant when I have sex”
Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.
A community nurse enters the home of the client for follow-up visit.
Which of the following is the most appropriate area to place the nursing
bag of the nurse when conducting a home visit?
B. bedside wood table
A wood surface provides the least chance for organisms to be present.
The nurse in the health center is making an assessment to the infant
client. The nurse notes some rashes and small fluid-filled bumps in the
skin. The nurse suspects that the infant has eczema. Which of the
following is the most important nursing goal:
A. Preventing infection
Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.
The nurse in the health center is providing immunization to the
children. The nurse is carefully assessing the condition of the
children before giving the vaccines. Which of the following would the
nurse note to withhold the infant’s scheduled immunizations?
B. a skin rash
A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.
A mother brought her child in the health center for hepatitis B
vaccination in a series. The mother informs the nurse that the child
missed an appointment last month to have the third hepatitis B
vaccination. Which of the following statements is the appropriate
nursing response to the mother?
C. “Your child will get the next dose as soon as possible”
Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.
The community health nurse implemented a new program about effective
breast cancer screening technique for the female personnel of the health
department of Valenzuela. Which of the following technique should the
nurse consider to be of the lowest priority?
B. Detailed health history to identify women at risk
Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.
Which of the following technique is considered an aseptic practice
during the home visit of the community health nurse?
B. Washing hands before removing equipment from the nursing bag
Washing hands before removing equipment from the nursing bag is considered an aseptic practice because it helps to prevent the transfer of microorganisms from the nurse's hands to the equipment. This reduces the risk of infection for both the nurse and the client. By washing hands, the nurse can effectively remove any potential pathogens that may be present on their hands before handling the equipment, ensuring a clean and sterile environment.
The nurse is planning to conduct a home visit in a small community.
Which of the following is the most important factor when planning the
best time for a home care visit?
A. Purpose of the home visit
The purpose of the visit takes priority.
The nurse assigned in the health center is counseling a 30-year-old
client requesting oral contraceptives. The client tells the nurse that
she has an active yeast infection that has recurred several times in the
past year. Which statement by the nurse is inaccurate concerning
health promotion actions to prevent recurring yeast infection?
D. “Douche once a day with a mild vinegar and water solution”
Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.
During immunization week in the health center, the parent of a
6-month-old infant asks the health nurse, “Why is our baby going to
receive so many immunizations over a long time period?” The best
nursing response would be:
A. “The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.”
Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.
The community health nurse is conducting a health teaching about
nutrition to a group of pregnant women who are anemic and are lactose
intolerant. Which of the following foods should the nurse especially
encourage during the third trimester?
C. Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements
This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.
A woman with active tuberculosis
(TB) and has visited the health center for regular therapy for five
months wants to become pregnant. The nurse knows that further
information is necessary when the woman states:
D. “I can get pregnant after I have been free of TB for 6 months”
Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to be free of TB before she should attempt pregnancy.
The Department of Health is alarmed that almost 33 million people suffer
from food poisoning every year. Salmonella enteritis is responsible for
almost 4 million cases of food poisoning. One of the major goals is to
promote proper food preparation. The community health nurse is tasks
to conduct health teaching about the prevention of food poisoning to a
group of mother everyday. The nurse can help identify signs and
symptoms of specific organisms to help patients get appropriate
treatment. Typical symptoms of salmonella include:
C. Diarrhea and abdominal cramps
Salmonella organisms cause lower GI symptoms
A community health nurse makes a home visit to an elderly person
living alone in a small house. Which of the following observation would be a great concern?
C. Shiny floors with scattered rugs
It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.
The health nurse is conducting health teaching about “safe” sex to a
group of high school students. Which of the following statement about
the use of condoms should the nurse avoid making?
C. “Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases”
Condoms do not prevent ALL forms of sexually transmitted diseases.
The department of health is promoting the breastfeeding program to all
newly mothers. The nurse is formulating a plan of care to a woman who
gave birth to a baby girl. The nursing care plan for a breast-feeding
mother takes into account that breast-feeding is contraindicated when
A. Is pregnant
Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.
The City health department conducted a medical mission in Barangay
Marulas. Majority of the children in the Barangay Marulas were
diagnosed with pinworms. The community health nurse should
anticipate that the children’s chief complaint would be:
C. Perianal itching
Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.
The mother brought her daughter to the health center. The child has
head lice. The nurse anticipates that the nursing diagnosis most
closely correlated with this is:
C. Altered comfort related to itching
Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.
The mother brings a child to the health care clinic because of severe
headache and vomiting. During the assessment of the health care nurse,
the temperature of the child is 40 degree Celsius, and the nurse notes
the presence of nuchal rigidity. The nurse is suspecting that the child
might be suffering from bacterial meningitis. The nurse continues to
assess the child for the presence of Kernig’s sign. Which finding would
indicate the presence of this sign?
C. Inability of the child to extend the legs fully when lying supine
Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.
A community health nurse makes a home visit to a child with an
and communicable disease. In planning care for the child, the nurse
must determine that the primary goal is that the:
C. Child will not spread the infection to others
The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.
The mother brings her daughter to the health care clinic. The child was
diagnosed with conjunctivitis. The nurse provides health teaching to
the mother about the proper care of her daughter while at home. Which
statement by the mother indicates a need for additional information?
A. “I do not need to be concerned about the spreading of this infection to others in my family”
Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.
A community health nurse is caring for a group of flood victims in
Marikina area. In planning for the potential needs of this group, which
is the most immediate concern?
D. Meeting the basic needs to ensure that adequate food, shelter and clothing are available
The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing.