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NCLEX child health questions with complete
solution
1. Which of the following is the most appropriate location for assessing the pulse of an infant who is less than 1
year old?: 1. Radial
2. Carotid
3. Brachial
- Popliteal Rationale: To assess a pulse in an infant (i.e., a child <1 year old), the pulse is checked at the brachial artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant.
- A nurse is teaching cardiopulmonary resuscitation to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student under- stands the reason if the student makes which statement?: 1. "The object may have been swallowed."
- "The infant may bite down on the finger"
- "The mouth is too small to see the object." 4. "The object may be forced back further into the throat." Rationale: Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object further down into the airway. Options 1, 2, and 3 are not related directly to the subject of the question.
- A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by:: 1. Testing the child's urine for specific gravity
2. Asking the child what happens during a seizure
3. Obtaining a family history of psychiatric illness
4. Obtaining a history regarding factors that may occur before the seizure activity
Rationale: Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test, because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.
4. A child has a basilar skull fracture. Which of the following health care provider's prescriptions should the
nurse question?: 1. Restrict fluid intake.
- Insert an indwelling urinary catheter.
- Keep an intravenous (IV) line patent. 4. Suction via the nasotracheal route as needed. Rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary.
- Which of the following represents a primary characteristic of autism?: 1. Normal social play
- Consistent imitation of others' actions 3. Lack of social interaction and awareness
- Normal verbal and nonverbal communication Rationale: Autism is a severe form of an autism spectrum disorder. A primary characteristic is a lack of social interaction and awareness. Social behaviors in autism include a lack of or an abnormal imitation of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and markedly abnormal nonverbal communication.
6. A nurse is assisting with data collection from an infant who has been diag- nosed with hydrocephalus. If the
infant's level of consciousness diminishes, a priority intervention is:: 1. Taking the apical pulse
2, 3, and 4 are incorrect. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.
9. A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the
child has a seizure? Select all that apply.: 1. Time the seizure.
2. Restrain the child.
3. Stay with the child.
- Place the child in a prone position. 5. Move furniture away from the child.
- Insert a padded tongue blade into the child's mouth. Rationale: During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration, because saliva will drain out of the corner of the child's mouth. The child is not restrained, because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure.
10. The appropriate child position after a tonsillectomy is which of the follow- ing?: 1. Supine position
2. Side-lying position
3. High Fowler's position
4. Trendelenburg's position
Rationale: The child should be placed in a semi-prone or side-lying position after tonsillectomy to facilitate drainage. Options 1, 3, and 4 will not achieve this goal.
11. After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to:: *1.
Turn the child to the side.*
2. Notify the RN or health care provider (HCP).
3. Administer the prescribed antiemetic.
4. Maintain nothing-by-mouth (NPO) status.
Rationale: After a tonsillectomy, if bleeding occurs, the child is turned to the side, and the RN or HCP is notified. An NPO status would be maintained, and an
following statements, if made by the mother, would indicate the need for further instruction?: 1. "I will give my child cough syrup if a cough develops."
2. "During an attack, I will take my child to a cool location."
3. "I will give acetaminophen (Tylenol) if my child develops a fever."
4. "I will be sure that my child drinks at least three to four glasses of fluids every day."
Rationale: Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.
15. A nurse who is working in the emergency department is caring for a child who has been diagnosed with
epiglottitis. Indications that the child may be experiencing airway obstruction include which of the following?: 1. Nasal flaring and bradycardia 2. The child thrusts the chin forward and opens the mouth
3. A low-grade fever and complaints of a sore throat
4. The child leans backward, supporting himself or herself with the hands and arms
Rationale: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, a high fever, and a sore throat.
16. A nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory
syncytial virus (RSV). On the basis of this finding, which of the following would be the appropriate nursing action?: 1. Initiate strict enteric precautions.
- Wear a mask when caring for the child. 3. Plan to move the infant to a room with another child with RSV.
- Leave the infant in the present room, because RSV is not contagious.
Rationale: RSV is a highly communicable disorder, but it is not transmitted via the airborne route. It is usually transferred by the hands, and meticulous handwashing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary; however, the nurse should wear a gown when the soiling of clothing may occur.
17. A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures.
Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis?: 1. A veggie salad and a caramel apple
- A strawberry jelly sandwich and pretzels
- A plate of nachos and cheese and a cupcake 4. A piece of fried chicken and a loaded baked potato Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. A piece of fried chicken and a loaded baked potato provides a high-calorie and high-protein meal that includes fat.
18. A nurse reviews the results of a Mantoux test performed on a 3-year-old child. The results indicate an
area of induration that measures 10 mm. The nurse would interpret these results as:: 1. Positive
2. Negative
3. Inconclusive
4. Definitive, requiring a repeat test
Rationale: An induration that measures 10 mm or more is considered to be a positive result for children who are younger than 4 years old and for those with chronic illness or with a high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for those in the highest-risk groups. Repeat
sures should be taught; these include frequent handwashing and not sharing towels and washcloths. Options 1, 2, and 4 are correct measures.
22. A nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The
nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, the nurse takes which action?: 1. Documents the findings
2. Notifies the registered nurse immediately
3. Changes the ear tubes so that they do not become blocked
4. Checks the ear drainage for the presence of cerebrospinal fluid
Rationale: After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, and 4 are not necessary.
23. A nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 2-year-old
child. Which of the following would be included in the plan?: 1. Wear gloves when administering the eardrops.
2. Pull the ear up and back before instilling the eardrops.
3. Pull the earlobe down and back before instilling the ear drops.
- Hold the child in a sitting position when administering the ear drops. Rationale: When administering eardrops to a child who is less than 3 years old, the ear should be pulled down and back. For children who are more than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but handwashing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.
24. A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory
*syncytial virus (RSV). Choose the inter- ventions that would be included in the plan of care. Select all that
apply.:* 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station.
3. Ensure that the infant's head is in a flexed position.
4. Wear a mask at all times when in contact with the infant.
5. Place the child in a tent that delivers warm, humidified air.
6. Position the infant side-lying, with the head lower than the chest.
Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.
25. A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has
documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate?: 1. Pallor
2. Hyperactivity
3. Exercise intolerance
- Gastrointestinal disturbances Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.
26. A nurse has reinforced home care instructions to the mother of a child who is being discharged after
Rationale: Anti-inflammatory agents, including aspirin, may be prescribed by the health care provider for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections such as influenza because of the risk of Reye's syndrome. Options 1 and 2 are clinical manifestations of RF. Facial edema may be associated with the development of a cardiac complication.
29. A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the
child's medical history, which clinical manifestation is likely to be reported?: 1. Cracked lips
- A normal appearance 3. Conjunctival hyperemia
4. Desquamation of the skin
Rationale: During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.
30. A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of
congestive heart failure (CHF). The nurse looks for which early sign of CHF?: 1. Pallor
- Cough 3. Tachycardia
- Slow and shallow breathing Rationale: The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with CHF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with CHF, but it is also not an early sign.
31. A health care provider has prescribed oxygen as needed for a 10-year-old child with congestive heart failure
(CHF). In which situation would the nurse administer the oxygen to the child?: 1. When the child is sleeping
2. When changing the child's diapers
3. When the mother is holding the child
4. When drawing blood for the measurement of electrolyte levels Rationale: Oxygen administration may be prescribed for the infant with CHF for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.
32. A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the
following alerts the nurse to suspect fluid accumu- lation and thus to the need to notify the registered nurse?: 1. Bradypnea
2. Diaphoresis
3. Decreased blood pressure (BP)
4. A weight gain of 1 lb in 1 day Rationale: A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of CHF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities.
33. A nurse provides home care instructions to the parents of a child with congestive heart failure regarding
the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction?: 1. "I will not mix the medication with food."
2. "If more than one dose is missed, I will call the health care provider."
3. "I will take my child's pulse before administering the medication."
4. "If my child vomits after medication administration, I will repeat the dose." Rationale: The parents need to be instructed that, if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed and it is not noticed until 4 hours later, the dose
4. Foul-smelling, ribbon-like stools Rationale: Chronic constipation that begins during the first month of life and that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are incorrect.
36. A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would
the nurse expect to note in this child?: 1. Watery diarrhea
2. Ribbon-like stools
3. Profuse projectile vomiting
4. Blood and mucus in the stools Rationale: The child with intussusception classically presents with severe abdom- inal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. Vomiting may be present, but it is not projectile. Bright red blood and mucus are passed through the rectum and commonly described as currant jelly-like stools. Ribbon-like stools are not a manifestation of this disorder.
37. A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces
instructions to the parents about the signs of possible hernial strangulation. The nurse tells the parents that which of the following signs would require health care provider (HCP) notification by the parents?: 1. Fever
2. Diarrhea
3. Vomiting
- Constipation Rationale: The parents of a child with a hernia need to be instructed about the signs of strangulation. These signs include vomiting, pain, and an irreducible mass. The parents should be instructed to contact the HCP immediately if strangulation is suspected. Fever, diarrhea, and constipation are not associated with strangulation of a hernia.
38. A nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the
child and the prevention of the transmis- sion of the virus. Which statement by a parent indicates a need for further instruction?: 1. "Frequent handwashing is important." 2. "I need to provide a well-balanced, high-fat diet to my child."
3. "I need to clean contaminated household surfaces with bleach."
4. "Diapers should not be changed near any surfaces that are used to prepare food."
Rationale: The child with hepatitis should consume a well-balanced, low-fat diet to allow the liver to rest. Options 1, 3, and 4 are components of the home-care instructions to the family of a child with hepatitis.
39. A nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement, if made by the
student, indicates an understanding of this disorder?: 1. "PKU is an autosomal-dominant disorder."
2. "PKU primarily affects the gastrointestinal system."
3. "Treatment of PKU includes the dietary restriction of tyramine."
4. "All 50 states require routine screening of all newborns for PKU." Rationale: PKU is an autosomal-recessive disorder. Treatment includes the dietary restriction of phenylalanine intake (not tyramine intake). PKU is a genetic disorder that results in central nervous system (CNS) damage from toxic levels of phenylala- nine in the blood.
40. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse
reinforces instructions regarding how to prevent hypoglycemia during practice. The nurse tells the child to:: 1. Drink a half a cup of orange juice before soccer practice.
2. Eat twice the amount that is normally eaten at lunchtime.
3. Take half of the amount of prescribed insulin on practice days.
4. Take the prescribed insulin at noontime rather than in the morning.
Rationale: An extra snack of 10 g to 15 g of carbohydrates eaten before activities and for every 30 to 45 minutes of
3. Electronic
4. Tympanic
Rationale: Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.
44. An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the
lip. The best position in which to place this infant at this time is:: 1. A flat position
- A prone position 3. On his or her left side
- On his or her right side Rationale: After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case, it is best to place the infant on his or her left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.
45. A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of
esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record?: 1. Incessant crying
2. Coughing at nighttime
3. Choking with feedings
- Severe projectile vomiting Rationale: Any child who exhibits the "3 Cs"—coughing and choking during feed- ings and unexplained cyanosis— should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.
46. A nurse is reviewing the record of a child with a diagnosis of pyloric steno- sis. Which data would the nurse
expect to note as having been documented in the child's record?: 1. Watery diarrhea 2. Projectile vomiting
3. Increased urine output
4. Vomiting large amounts of bile
Rationale: Clinical manifestations of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.
47. A nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose
intolerance. The nurse tells the mother that which of the following supplements will be required as a result of the need to avoid lactose in the diet?: 1. Fats
2. Zinc
3. Calcium
- Thiamine Rationale: Lactose intolerance is the inability to tolerate lactose, which is the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and, if the child is an infant, protein and calories.
48. A nurse reinforces home-care instructions to the parents of a child with celiac disease. Which of the
following food items would the nurse advise the parents to include in the child's diet?: 1. Rice
2. Oatmeal
3. Rye toast
4. Wheat bread
Rationale: Dietary management is the mainstay of treatment for celiac disease.
