hospital 10
a nurse is teaching a parent of a toddler about parallel play in children. which if the following should the nurse include? 1. children sit and observe 2.childern exhibit organized play in group 3.the child plays alone 4.the child plays independently when in a group
4.the child plays independently when in a group
A nurse is assessing an infant who is suspected of having a congenital heart defect. Which of the following findings would support this suspicion? (Select all that apply.)
A. Failure to thrive and poor weight gain
B. Cyanosis and pallor
C. Tachypnea and dyspnea
D. Excessive perspiration, especially over the forehead during feeding
E. Clubbing of fingers
F. Mild diaper rash
Correct Answers: A, B, C, D, E
A. Failure to thrive and poor weight gain → Common in infants with congenital heart defects due to increased energy needs and poor feeding.
B. Cyanosis and pallor → Indicate poor oxygenation and circulation.
C. Tachypnea and dyspnea → Related to increased pulmonary blood flow or heart failure.
D. Excessive perspiration, especially over the forehead during feeding → Classic finding in infants with cardiac pathology; feeding is as strenuous as exercise.
E. Clubbing of fingers → Seen with chronic hypoxemia.
F. Mild diaper rash → Not related to cardiac pathology.
A nurse is caring for an adolescent following surgery. Which of the following nursing actions is priority to promote coping?
A. Provide consistency with one caregiver
B. Involve the adolescent in planning care
C. Encourage dramatic play with dolls and puppets
D. Allow parents to stay in the room at all times
15. Multiple Choice
Answer: B. Involve the adolescent in planning care
Rationale: Adolescents value independence, autonomy, and body image. Including them in care helps with coping.
A = infant/toddler stage.
C = preschool stage (dramatic play).
D = adolescents may want parents nearby, but peers and independence are more important.
A nurse is providing care to a school-aged client who has heart failure. The client asks if they are permitted to continue to participate in physical
education at school following their diagnosis. Which of the following statements should the nurse make?
1."You are allowed to participate in physical education, and you should get at least 60 minutes of physical activity daily.
" 2."You should not participate in physical activity, because this could worsen your heart failure."
3."You should only participate in individual activities and should not partake in team sports."
4."You are allowed to participate in physical activity, but it should be limited to 30 minutes per day."
"You are allowed to participate in physical education, and you should get at least 60 minutes of physical activity daily."
Clients who have heart failure are encouraged to continue to take part in physical activity as they are able to tolerate it. They are encouraged to
engage in at least 60 min of physical activity per day.
A nurse is preparing to discharge a school aged client who was admitted for sickle cell pain crisis. At discharge, the client reports pain in their back as a 3 on
a pain scale of 0 to 10. Which of the following interventions should the nurse include when educating the client's parents about appropriate pain
management? Select all that apply.
Deep breathing exercises
Warm compress
Hydration
Over the counter analgesics
Ice pack
Deep breathing exercises is correct. Deep breathing exercises can help alleviate pain and provide something to focus on other than the client's pain.
Over the counter analgesics is correct. Ibuprofen and acetaminophen can be used over the counter for pain management as advised by the provider.
Hydration is correct. Hydration can improve circulation and prevent dehydration, which can be a precipitating factor for vaso-occulsive crisis leading to pain.
Warm compress is correct. Warm compresses can help improve blood circulation where there is pain by promoting vasodilation.
A nurse is caring for a hospitalized preschooler who refuses to take oral medication. Which nursing intervention is most appropriate to encourage compliance?
A. Offer the child a choice of taking the medicine with juice or applesauce.
B. Explain to the child that they must take the medicine “because the nurse said so.”
C. Tell the child that if they don’t take the medicine, they will have to get a shot.
D. Allow the child to skip the dose and try again at the next scheduled time.
Answer: A. Offer the child a choice of taking the medicine with juice or applesauce.
Rationale: Preschoolers value independence and respond well when given simple, limited choices. This helps them feel a sense of control while still ensuring the medication is taken.
B = Too authoritarian; likely increases resistance.
C = Threatening with punishment (shot) increases fear and mistrust.
D = Skipping a dose compromises safe medication administration.
A nurse is assessing a client who presents to the emergency department and reports having a fever for the past 5 days. The nurse should
recognize that which of the following findings may indicate Kawasaki disease? (Select all that apply.)
Conjunctivitis
Increased thirst
Lymphadenopathy
Mucositis
Strawberry tongue
Chest pain
Conjunctivitis is correct. Clinical manifestations of Kawasaki disease include fever, conjunctivitis, mucositis, strawberry tongue, rash, desquamation, and lymphadenopathy.
Increased thirst is incorrect. Nonspecific findings associated with Kawasaki disease can include decreased oral intake and joint pain.
Lymphadenopathy is correct. Clinical manifestations of Kawasaki disease include fever, conjunctivitis, mucositis, strawberry tongue, rash, desquamation, and lymphadenopathy.
Mucositis is correct. Clinical manifestations of Kawasaki disease include fever, conjunctivitis, mucositis, strawberry tongue, rash, desquamation, and lymphadenopathy.
Strawberry tongue is correct. Clinical manifestations of Kawasaki disease include fever, conjunctivitis, mucositis, strawberry tongue, rash, desquamation, and lymphadenopathy.
Chest pain is incorrect. Clinical manifestations of Kawasaki disease include fever, conjunctivitis, mucositis, strawberry tongue, rash, desquamation, lymphadenopathy. Chest pain is not indicative of Kawasaki disease.
A nurse is caring for an infant client who has sickle cell anemia. The guardian of the infant is seeking advice on steps to reduce the risk of infection for the
child. After the nurse provides education, which of the following responses by the guardian indicates an understanding of infection prevention? Select all
that apply.
"My child should take prophylactic antibiotics until at least five years of age."
"My child should only receive inactivated vaccines."
"My child should receive the influenza and pneumococcal vaccines annually."
"My child should not receive the influenza vaccine annually."
"My child does not need to be on daily prophylactic medication until five years old."
"My child should receive the influenza and pneumococcal vaccines annually" is correct. Infection prevention should be a focus of health promotion in clients with sickle cell disease. Pediatric clients with sickle cell disease should adhere to the childhood vaccine schedule and receive the influenza vaccine annually, as well
as the pneumococcal vaccine.
"My child should take prophylactic antibiotics until at least five years of age" is correct. Clients with sickle cell disease are started on prophylactic penicillin until 5 years of age. Adhering to the prescribed dosage and schedule is an important factor for infection prevention.
The nurse is planning play activities for children of different age groups. Which of the following are appropriate? (Select all that apply.)A. Infants: colorful mobiles and soft toys
B. Toddlers: large crayons and push-pull toys
C. Preschoolers: dramatic play and tricycles
D. School-age children: organized team sports and crafts
E. Adolescents: associative play with toddlers
Answers: A, B, C, D
A. Infants → colorful mobiles, soft toys ✅
B. Toddlers → crayons, push-pull toys ✅
C. Preschoolers → dramatic play, tricycles ✅
D. School-age children → organized team sports, crafts ✅
E. Adolescents: associative play with toddlers ❌ (adolescents engage in peer interaction, team sports, music, reading—not toddler play).
A nurse is providing care to a toddler who has a diagnosis of heart failure. The toddler's caregivers are concerned that the child is not meeting motor milestones at the same ages that their older siblings did. Which of the following statements should the nurse provide?
"Children who have heart failure are not at risk for delayed milestones and should be meeting milestones as expected."
"Children who have heart failure may experience delayed motor milestones because of poor nutrition and weight gain."
"Children who have heart failure will likely develop physical and cognitive disability. This is an expected finding for your child."
"All children develop at their own pace. You should not be comparing your child to their siblings' development. Your child will eventually catch
up."
"Children who have heart failure may experience delayed motor milestones because of poor nutrition and weight gain."
CORRECT
Poor nutrition and weight gain can contribute to delayed motor milestones in pediatric clients who have heart failure and is associated with poor
outcomes.
A nurse is planning care for a preschool-age child who is hospitalized. Which of the following should the nurse anticipate? (Select all that apply.)
A. Limited understanding of the cause of illness
B. Belief that illness may be a punishment
C. Separation anxiety from parents
D. Fear of loss of control
E. Magical thinking about illness
SATA
Answers: A, B, E
A. Limited understanding of the cause of illness → Preschoolers don’t fully grasp cause/effect.
B. Belief illness may be a punishment → Magical thinking common at this age.
E. Magical thinking about illness → They may think their thoughts caused the illness.
C = separation anxiety → more intense in toddlers.
D = fear of loss of control → school-age childre
A 4-month-old infant with Tetralogy of Fallot suddenly becomes cyanotic and irritable during a blood draw. Which action should the nurse take first?
A. Place the infant in a knee-to-chest position
B. Administer morphine sulfate as prescribed
C. Provide 100% oxygen by face mask
D. Notify the provider immediately
You said:
ChatGPT said:
✅ You got it! The correct answer is:
A. Place the infant in a knee-to-chest position
Rationale:
During a tet spell (acute cyanotic episode in TOF), the priority is positioning — placing the infant in a knee-to-chest position. This increases systemic vascular resistance, decreases right-to-left shunting, and improves oxygenation.
B. Morphine sulfate → correct, but it’s done after positioning to calm the child and decrease oxygen demand.
C. Oxygen by mask → helpful but not as effective as positioning for immediate relief.
D. Notify provider → important, but only after stabilizing the infant.