1. The nurse is caring for a pre-adolescent client in skeletal Dunlop
traction. Which nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
✓ A: Make certain the child is maintained in correct body alignment.
2. The nurse is assessing a healthy child at the 2 year check up.
Which of the following should the nurse report immediately to the
health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
✓ A: Height and weight percentiles vary widely
3. The parents of a 2 year-old child report that he has been holding
his breath whenever he has temper tantrums. What is the best
action by the nurse?
A) Teach the parents how to perform cardiopulmonary
resuscitation
B) Recommend that the parents give in when he holds his breath to
prevent anoxia
C) Advise the parents to ignore breath holding because breathing
will begin as a reflex
D) Instruct the parents on how to reason with the child about
possible harmful effects
✓ C: Advise the parents to ignore breath holding because breathing
will begin as a reflex
4. The nurse is assessing a client in the emergency room. Which
statement suggests that the problem is acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
2
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
✓ A: "My pain is deep in my chest behind my sternum."
5. The nurse is assessing the mental status of a client admitted
with possible organic brain disorder. Which of these questions will
best assess the function of the client's recent memory?
A) "Name the year." "What season is this?" (pause for answer after
each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for
answer) "Now continue to subtract 7 from the new number."
C) "I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask,
"What is the purpose of it?"
✓ C: "I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen."
6. In planning care for a 6 month-old infant, what must the nurse
provide to assist in the development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
✓ C: Security
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