Question

A nurse is caring for a 2-year-old child who has pneumonia. The child's parents are unable to be with the child in the hospital during the day due to work schedules. While the child is alone during the day, they have several crying episodes which cause increased periods of respiratory distress, exhibiting manifestations such as tachypnea and decreased oxygen saturation levels. Which of the following interdisciplinary care team members would be beneficial to include in the child's plan of care?

Answer 1

Correct Answers:

Child life specialist

Rationale :

💠A child life specialist is trained to help children cope with the stress and anxiety of hospitalization, particularly when separated from parents.

💠They use developmentally appropriate play, distraction, and therapeutic communication to reduce fear, loneliness, and crying.

💠For a 2-year-old, who experiences separation anxiety and cannot fully verbalize emotions, this support minimizes emotional distress that can worsen respiratory effort.

💠By promoting a sense of security and routine, the child life specialist indirectly helps stabilize breathing patterns and oxygen levels.

💠Their involvement fosters emotional comfort, enhances cooperation during care, and supports optimal recovery.

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Answer 2

Correct Answers:

"Adolescents are more likely to engage in risky driving behaviors, such as speeding and impaired driving."

Rationale :

🔹Adolescents often display impulsivity, peer influence, and a sense of invincibility, making them prone to risky driving behaviors.

🔹These include speeding, distracted driving, and driving under the influence, which contribute significantly to motor-vehicle injuries in this age group.

🔹The nurse’s teaching should promote awareness and responsibility, focusing on seat belt use, sober driving, and avoidance of mobile phones.

🔹Education that links risk behavior to real consequences helps adolescents develop safer driving habits.

🔹Emphasizing decision-making skills and accountability supports long-term prevention of road-related trauma.

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Answer 3

Correct Answers:

Face, Legs, Activity, Cry ,Consolability (FLACC)

Rationale :

🔷The FLACC scale is designed for infants and young children who cannot verbalize pain effectively (ages 2 months–7 years).

🔷It assesses five behavioral cues—facial expression, leg movement, activity, cry, and consolability—each scored 0–2 for a total of 0–10.

🔷It provides an objective and reliable measure of pain intensity in preverbal children.

🔷The tool enables nurses to detect changes early, ensuring timely analgesic administration and comfort.

🔷Using FLACC supports standardized pain assessment consistent with pediatric best practices.

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Answer 4

Correct Answers:

"l am going to listen to your heart"

Rationale :

🟣When communicating with toddlers, nurses must use simple, concrete, and non-threatening language.

🟣Saying “listen to your heart” explains the procedure clearly without causing fear, unlike words such as “take” or “measure,” which may sound frightening.

🟣Age-appropriate explanations enhance trust and reduce anxiety, making cooperation easier during assessments.

🟣Therapeutic communication fosters a sense of control for the child, promoting smoother interactions.

🟣This approach aligns with Erikson’s stage of autonomy vs. shame and doubt, supporting positive experiences in healthcare.

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Answer 5

Correct Answers:

5.3

Rationale :

✍️Weight conversion:

🟢28 lb × 0.45

12.6 kg.

✍️Ordered dose:

🟢10 mg/kg = 10 × 12.6

126 mg per dose.

✍️Available concentration:

🟢120 mg / 5 mL.

✍️Formula:

🟢 120 mg/5 mL=126 mg/x mL⇒x=126×5/120

=5.25

≈5.3 mL

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Answer 6

Correct Answers:

Allow the toddler to sit on the parent's lap and begin the assessment.

Rationale :

🔶Allowing the toddler to sit on the parent’s lap promotes security and trust, minimizing fear and distress.

🔶Toddlers exhibit separation anxiety, especially in unfamiliar settings, and perform best when caregivers remain present.

🔶This positioning allows the nurse to perform much of the assessment while maintaining comfort and cooperation.

🔶Physical restraint or forcing compliance may increase crying, resistance, and physiological stress.

🔶The approach aligns with family-centered care principles, ensuring a positive developmental experience.

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Answer 7

Correct Answers:

"Toddlers are beginning to develop a desire for autonomy. Temper tantrums are normal during this stage."

Rationale :

💎According to Erikson’s psychosocial stage of autonomy vs. shame and doubt, toddlers strive for independence and control.

💎When autonomy efforts are restricted, frustration leads to temper tantrums, which are a normal developmental behavior.

💎The nurse should reassure the parent that tantrums signify healthy emotional growth, not poor parenting.

💎Education should include strategies such as consistent limits, positive reinforcement, and calm redirection.

💎This response supports parental confidence and age-appropriate behavioral understanding.

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Answer 8

Correct Answers

Blank 1 Correct Option: neurological status
Blank 2 Correct Option: growth chart results

Rationale :

💠The growth chart shows that the infant’s head circumference has increased from 34.5 cm at birth (75th percentile) to 41.1 cm at 2 months (>99th percentile).

💠This represents a rapid and disproportionate growth compared to the infant’s weight (50th percentile) and length (75th percentile).

💠Such accelerated head growth raises concern for neurological abnormalities, particularly hydrocephalus—an excessive accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure (ICP).

💠The infant’s clinical symptoms—vomiting after feedings, irritability, excessive sleepiness, and fussiness—further support this suspicion.

💠These are classic early warning signs of increased ICP in infants, who cannot yet verbalize headaches or visual changes.

💠Neurological assessment should therefore be prioritized. This includes evaluating fontanel fullness or bulging, head symmetry, eye movements (sunset sign), cry characteristics, and motor responses.

💠Any abnormal findings may require urgent neuroimaging (ultrasound or MRI) and neurology referral.

💠The nurse uses growth chart data as a vital diagnostic clue in pediatric practice.

💠Recognizing disproportionate head growth trends is essential to detect neurological pathologies early, prevent permanent damage, and ensure timely interdisciplinary intervention.

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Answer 9

Correct Answers:

BP 79/40 mm Hg, heart rate 135/min, respirations 32 / min and oral temperature of 38°C (100.4° F)

Rationale :

♦️For a 2-year-old, normal parameters are: BP ≈ 86–106/42–63 mm Hg, HR 98–140/min, RR 22–37/min, and Temp 36.5–37.5 °C.

♦️The given blood pressure of 79/40 mm Hg is below the normal systolic range, indicating hypotension, a potential early sign of shock or sepsis.

♦️The tachycardia (135/min) and mild fever (38 °C) further support the possibility of infection with early circulatory compromise.

♦️Hypotension in pediatrics is a late and serious finding; immediate provider notification allows for prompt fluid and infection management.

♦️Early recognition prevents decompensation, as children can maintain perfusion until a sudden, rapid decline occurs.

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Answer 10

Correct Answers:

Encourage the client to complete school work.

Rationale :

🔹According to Erikson’s psychosocial stage of Industry vs. Inferiority (ages 6–12 years), children seek to develop competence and mastery in school and social tasks.

🔹Continuing academic activities helps the hospitalized child maintain a sense of productivity, normalcy, and self-worth.

🔹Hospitalization disrupts peers and schooling, so incorporating age-appropriate responsibilities reduces feelings of inferiority.

🔹The nurse’s role includes facilitating schoolwork, structured routines, and goal setting to meet developmental needs.

🔹This supports positive coping and adjustment, ensuring the child’s identity and confidence remain intact during hospitalization.

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QLexNursing

2 :
A school nurse is teaching a group of adolescents about risks associated with unsafe driving. Which of the following statements should the nurse include?

3 :
A nurse is assessing pain in a 6-month-old infant. Which of the following assessment tools should the nurse use?

4 :
A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

5 :
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse is the best option?

7 :
A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?

8 :
A nurse is caring for an infant in a pediatric clinic.

Correct Answers

9 :
A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

10 :
A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

QLexNursing

2 : A school nurse is teaching a group of adolescents about risks associated with unsafe driving. Which of the following statements should the nurse include?

3 : A nurse is assessing pain in a 6-month-old infant. Which of the following assessment tools should the nurse use?

4 : A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

5 : A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 : A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse is the best option?

7 : A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?

8 : A nurse is caring for an infant in a pediatric clinic.

Correct Answers

9 : A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

10 : A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

2 :
A school nurse is teaching a group of adolescents about risks associated with unsafe driving. Which of the following statements should the nurse include?

3 :
A nurse is assessing pain in a 6-month-old infant. Which of the following assessment tools should the nurse use?

4 :
A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

5 :
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse is the best option?

7 :
A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?

8 :
A nurse is caring for an infant in a pediatric clinic.

9 :
A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

10 :
A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?