Pediatric Nursing NCLEX Practice Exam:
Part 2
1. Stefan was diagnosed with secondary vesicoureteral
reflux; such condition usually results from which of the
following?
A. Acidic urine
B. Congenital defects
C. Hydronephrosis
D. Infection
Infection is the most common cause of secondary
vesicoureteral reflux. The possibility that UTI may cause
reflux has also been investigated. Indeed, a subset of
patients has been identified in whom reflux was
detectable only during an episode of cystitis.
Option A: Acidic urine is normal and helps to prevent
infection. According to the American Association for
Clinical Chemistry, the average value for urine pH is 6.0,
but it can range from 4.5 to 8.0. Urine under 5.0 is
acidic, and urine higher than 8.0 is alkaline, or basic.
Option B: Congenital defects cause primary
vesicoureteral reflux. Primary reflux is VUR in an
otherwise normally functioning lower urinary tract. Rates
of reflux are likely increased in the setting of congenital
bladder outlet obstruction and neurogenic bladder. More
than 50% of boys with posterior urethral valves have
VUR. Similar results were seen in a series of children
undergoing urodynamic studies for neurogenic bladder.
Option C: Hydronephrosis may result from
vesicoureteral reflux. Recurrent UTI, first febrile urinary
tract infection (UTI) with abnormal renal ultrasound (US)
are indications of VUR. Other indications are
prenatal/postnatal urinary tract dilatation, dysfunctional
voiding, bladder outlet obstruction, neurogenic bladder,
dysuria, hematuria, trauma.
2. Preferred nurses at the Nurseslabs Medical Center
are about to perform a procedure related to a
genitourinary (GU) problem to a group of pediatric
patients. Which of the following groups would find it
especially extra stressful?
A. Infants
B. Toddlers
C. Preschoolers
D. School-age children
In general, preschoolers have more fears because of
their fantasies, contributing to fears of the simplest
procedures. Castration fears are also prominent at this
age and may be heightened by procedures related to
GU problems. The human brain is wired to alert us to
and protect us from danger. Back in the day, that could
mean a panther or wolf attack—so some trepidation
around furry creatures is clearly in order. While babies
and toddlers are usually scared of animals, too, things
get turned up a notch when an active imagination kicks
in at this age, explains Dr. Chansky.
Option A: A common fear during infancy is stranger
anxiety, or a heightened awareness of strangers, which
peaks at around 6 to 8 months. Babies have, by then,
formed intimate relationships with people who care for
them. Unfamiliar people will stand out, and babies will
be sensitive to their personal space.
Option B: At about 3 ½, children often develop a variety
of insecurities and physical ways of showing them. Fear
of the dark and nightmares are common and may last
quite a while. Although many fears are specific to an
individual child, some seem to be very typical for this
age group-fear of strange animals, bathtub drains, fire,
thunder and lightning, snakes, and bugs.
Option D: Children are at a stage of development when
they may be worried about growing up and, instead,
want to remain little! Often, this is related to the fear of
going off to the “big” school and first grade. It is
important to allow children to feel their fears, discuss
them, and even allow them to stay home for a day, if
necessary.
3. What is most likely the underlying physiology of
primary enuresis?
A. Psychogenic stress
B. Delayed bladder maturation
C. Urinary tract infection
D. Vesicoureteral reflux
The most likely cause of primary enuresis is delayed or
incomplete maturation of the bladder. Primary enuresis
is that which occurs in a child who has not been dry for
at least 6 months, whereas secondary enuresis is the
one that has an onset after a period of nocturnal dryness
of at least 6 months.
Option A: Psychogenic stress may cause either primary
or secondary enuresis, but it is not the leading cause of
primary enuresis. Additionally, 20 to 30% of patients with
enuresis also suffer from at least one psychological,
behavioral, or psychiatric disorder, a rate twice as high
as that of the general population.
Option C: UTIs may cause either primary or secondary
enuresis, but they are not the leading cause of primary
enuresis. Enuresis is considered a multifactorial entity
with a strong genetic component that may be influenced
by comorbidities and immaturity of the central nervous
system bladder control mechanisms.
Option D: Vesicoureteral reflux may cause either
primary or secondary enuresis, but is not the leading
cause of primary enuresis. Bladder dysfunction is more
common in patients who also have daytime
incontinence, and it can manifest as diminished
functional bladder capacities or abnormal urodynamics,
as in nocturnal detrusor hyperactivity, which could be
associated with constipation, probably through bladder
distortion from a full rectum.
4. The nurse is aware that the following laboratory
values support a diagnosis of pyelonephritis?
A. Myoglobinuria
B. Ketonuria
C. Pyuria
D. Low white blood cell (WBC) count
Pyelonephritis is diagnosed by the presence of
leukocytosis, hematuria, pyuria, and bacteriuria. A
urinary specimen should be obtained for a urinalysis. On
urinalysis, one should look for pyuria as it is the most
common finding in patients with acute pyelonephritis.
Option A: As the name suggests, myoglobinuria means
the presence of an abnormally excessive amount of
myoglobin in the urine. As myoglobin is present in the
muscle cells, myoglobinuria is associated with damage
to the cell membranes of myocytes. Numerous
etiologies can lead to the rupture of the myocytes’ cell
membranes.
Option B: Ketonuria indicates a diabetic state. Nitrite
production will indicate that the causative bacteria is
E.coli. Proteinuria and microscopic hematuria may be
present as well on urinalysis. If hematuria is present,
then other causes may be considered such as kidney
stones.
Option D: The client exhibits fever, chills, and flank
pain. Because there is often a septic picture, the WBC
count is more likely to be high rather than low. Blood
work such as a complete blood cell count (CBC) is sent
to look for an elevation in white blood cells. The
complete metabolic panel can be used to search for
aberrations in creatinine and BUN to assess kidney
function.
5. Nurse Chole is evaluating a female child with acute
post-streptococcal glomerulonephritis for signs of
improvement. Which finding typically is the earliest sign
of improvement?
A. Increased urine output
B. Increased appetite
C. Increased energy level
D. Decreased diarrhea
Increased urine output, a sign of improving kidney
function, typically is the first sign that a child with acute
post-streptococcal glomerulonephritis (APSGN) is
improving. PSGN typically presents with features of the
nephritic syndrome such as hematuria, oliguria,
hypertension, and edema, though it can also present
with significant proteinuria.
Option B: Increased appetite is not specific to APSGN.
Poststreptococcal glomerulonephritis (PSGN) results
from a bacterial infection that causes rapid deterioration
of the kidney function due to an inflammatory response
following streptococcal infection.
Option C: An increased energy level is not specific to
APSGN. When symptomatic, PSGN typically presents
with features of the nephritic syndrome such as
hematuria, oliguria, hypertension, and edema. Less
common presentations can mimic nephrotic syndrome
with significant proteinuria.
Option D: Decreased diarrhea is not specific to APSGN.
The most common presenting symptom is gross
hematuria as it occurs in 30 to 50% of cases with acute
PSGN; patients often describe their urine as smoky, tea-
colored, cola-colored, or rusty.
6. Hannah’s child is scheduled for surgery due to
myelomeningocele; the primary reason for surgical
repair is which of the following?
A. To prevent hydrocephalus
B. To reduce the risk of infection
C. To correct the neurologic defect
D. To prevent seizure disorders
Surgical closure decreases the risk of infection
stemming from damage to the fragile sac, which can
lead to meningitis. Prenatal surgery was proven to be
more effective than postnatal surgery in lowering the
occurrence of future complications.
Option A: Surgical repair does not help relieve
hydrocephalus. In fact, some researchers believe that
repair exaggerates the Arnold-Chiari malformation and
decreases the absorptive surface for cerebrospinal fluid,
leading to the more rapid development of
hydrocephalus.
Option C: The neurologic deficit cannot be corrected.
However, some surgeons believe that early surgery
reduces the risk of stretching spinal nerves and
preventing further damage. Once the diagnosis has
been made, early surgical repair of the spinal lesion is
essential in preventing further deficits and neurological
damage.
Option D: Surgical repair of the sac doesn’t prevent
seizure disorder, an impairment of the brain neuron
tissue. If deciding to start drug therapy, many
medications are options to treat a chronic seizure
disorder or epilepsy as first-line medication or adjunctive
medications.
7. Tiffany is diagnosed with increased intracranial
pressure (ICP); which of the following if stated by her
parents would indicate a need for Nurse Charlie to
reexplain the purpose for elevating the head of the bed
at a 10 to 20-degree angle?
A. Help alleviate headache
B. Increase intrathoracic pressure
C. Maintain neutral position
D. Reduce intra-abdominal pressure.
Head elevation decreases, not increases, intrathoracic
pressure. In most patients with intracranial hypertension,
head and trunk elevation up to 30 degrees is useful in
helping to decrease ICP, providing that a safe CPP of at
least 70 mmHg or even 80 mmHg is maintained.
Option A: Elevating the head of the bed in a child with
increased ICP helps to alleviate headache which may
contribute to increased ICP. Therapeutic positioning of
the head (different degrees of head?of?bed elevation
(HBE)) has been proposed as a low-cost and simple
way of preventing secondary brain injury in these
people.
Option C: The position of the backrest of the bed is a
simple and cheap intervention. This is important as most
brain injury happens in low? and middle?income
countries with relatively undeveloped health systems
and few resources to deal with brain injury.
Option D: Elevated intra-abdominal pressure (IAP)
occurs in many clinical settings, including sepsis, severe
acute pancreatitis, acute decompensated heart failure,
hepatorenal syndrome, resuscitation with large volume,
mechanical ventilation with high intrathoracic pressure,
major burns, and acidosis.
8. In diagnosing seizure disorder, which of the following
is the most beneficial?
A. Skull radiographs
B. EEG
C. Brain scan
D. Lumbar puncture
The EEG recognizes abnormal electrical activity in the
brain. The pattern of multiple spikes can assist in the
diagnosis of particular seizure disorders.
Electroencephalography (EEG) is a biomarker for
epilepsy. Focal or generalized epileptiform discharges
constitute the EEG hallmark of seizure activity.
Frequently EEG is obtained as a risk-stratification tool
for a patient with a seizure of possibility of seizures.
Option A: Skull radiographs can distinguish fractures
and structural abnormalities. Currently, radiography is
mostly used to evaluate surgically implanted material
such as shunts, cochlear implants, intrathecal catheters,
and deep brain stimulators.
Option C: Brain scans confirm space-occupying lesions.
Neuroimaging is often obtained and is of higher yield
based on historical factors or focal findings on the
neurologic examination. Imaging is a recommendation
whenever there is suspicion of an acute intracranial
process in patients with a history of acute head trauma,
history of malignancy, immunocompromised, fever,
persistent headache, anticoagulation use, age older
than 40 years, or focal seizure onset.
Option D: Lumbar puncture confirms problems related
to cerebrospinal fluid infection or trauma. Lumbar
puncture should merit consideration in patients with
fever, a history of immunosuppression, or other factors
suggesting possible central nervous system infection.
9. Janae has a seizure disorder; which of the following
would be the lowest priority when caring for her?
A. Observing and taking down data on all seizures
B. Assuring safety and protection from injuring
C. Assessing for signs and symptoms of increased
intracranial pressure (ICP)
D. Educating the family about anticonvulsant therapy
Signs and symptoms of increased intracranial pressure
(ICP) are not associated with seizure activity and
therefore would be the lowest priority. A sudden
alteration in consciousness with associated motor
movements is the common description of a convulsive
seizure. For generalized seizures with associated motor
movements, the convulsion typically has a stiffening or
tonic phase followed by clonic movements – rhythmic
phased motor movements.
Option A: Careful observation and documentation of
seizures provide valuable information to aid prevention
and treatment. Frequently there will be a history of
unresponsive spells that, in retrospect, might be
seizures. Events leading up to the seizure are quite
important, and friends, family, or coworkers may have
crucial historical information.
Option B: Safety is always a priority in the care of a
child with seizure disorder because seizures may occur
at any given time. An epileptic seizure is a transient
occurrence with signs or symptoms due to abnormal
excessive and synchronous neuronal activity in the
brain.
Option D: Improper administration of and incomplete
compliance with anticonvulsant therapy can lead to
status epilepticus; thus education is a priority. For the
patient with known epilepsy, an obvious question would
be to ask if there has been any irregularity with
medication use.
10. While examining a 2-year-old child, Nurse Victoria
sees that the anterior fontanel is open. She should:
A. Notify the doctor
B. Look for other signs of abuse
C. Recognize this as a normal finding
D. Ask about a family history of Tay-Sachs disease
Because the anterior fontanel normally closes between
ages 12 and 18 months, the nurse should notify the
doctor promptly of this finding. The fontanel can enlarge
in the first few months of life, and the median age of
closure is 13.8 months. By three months of age, the
anterior fontanel is closed in 1 percent of infants; by 12
months, it is closed in 38 percent; and by 24 months, it
is closed in 96 percent.
Option B: An open fontanel does not indicate abuse.
Fontanel size is influenced by brain growth, dural
attachments, suture development, and osteogenesis.
The newborn’s skull should be evaluated for shape,
circumference, suture ridges, and size of anterior and
posterior fontanels. Size is calculated by the average of
the anteroposterior and transverse dimensions.
Option C: The key feature of a normal anterior fontanel
is variation. On the first day of an infant’s life, the normal
fontanel ranges from 0.6 cm to 3.6 cm, with a mean of
2.1 cm. The fontanel can enlarge in the first few months
of life and the median age of closure is 13.8 months.
Option D: An open fontanel is not associated with Tay-
Sachs disease. Achondroplasia, congenital
hypothyroidism, Down syndrome, rickets, and increased
intracranial pressure are among the most common
conditions associated with an open anterior fontanel.
11. Nurse Oliver is attending to a child with Cushing’s
syndrome. Which of the following nursing interventions
would be most necessary?
A. Observing the child for signs and symptoms of
metabolic acidosis
B. Handling the child carefully to prevent bruising
C. Monitoring vital signs for hypertension and
tachycardia
D. Monitoring the child for signs and symptoms of
hypoglycemia
The nurse should handle the child carefully because
Cushing’s syndrome causes capillary fragility, resulting
in easy bruising and calcium excretion, resulting in
osteoporosis. Glucocorticoids also increase catabolism
of proteinaceous tissues such as collagen, causing skin
atrophy fragility with striae and easy bruising.
Option A: Cushing’s syndrome causes increased
excretion of hydrogen ions, resulting in alkalosis and
increased water and sodium retention. High cortisol
levels also cause immune disruptions; this hormone
leads to a decrease in lymphocyte levels and increases
the neutrophils. It causes detachment of the marginating
pool of neutrophils in the bloodstream and increases the
circulating neutrophil levels although there is no
increased production of the neutrophils.
Option C: Cushing’s syndrome causes increased
excretion of potassium and hypokalemia resulting in a
sluggish and irregular heartbeat. Cortisol decreases
glomerular filtration rate, and renal plasma flow from the
kidneys thus increasing phosphate excretion, as well as
increasing sodium and water retention and potassium
excretion by acting on mineralocorticoid receptors.
Option D: Cushing’s syndrome causes hyperglycemia,
not hypoglycemia. The excess of cortisol results in an
increased rate of gluconeogenesis, glycogenolysis and
increases insulin resistance. Cortisol is a steroid
hormone, and it directly affects the transcription and
translation of enzyme proteins involved in the
metabolism of fats, glycogen, protein synthesis, and
Kreb’s cycle.
12. Nurse Aries entered the room of a child with
hypopituitarism and was asked by the couple about the
condition of their child. Which of the following phrases if
stated by the nurse best describes the condition?
A. Linear growth retardation with skeletal
proportions normal for chronologic age
B. A complete normal growth pattern, but with the onset
of precocious puberty
C. Normal growth for first five years, followed by
progressive linear growth retardation
D. Growth retardation in which height and weight are
equally affected
Although linear growth retardation occurs in
hypopituitarism, delayed epiphyseal maturation allows
for normal skeletal proportions. A population of full-term
infants born with either isolated CGHD or multiple
pituitary hormone deficiencies had normal lengths and
weights at birth. By 6 and 12 months of age, all
manifested growth deceleration.
Option B: The child with hypopituitarism commonly
experiences delayed sexual maturation. Follicle-
stimulating hormone (FSH) is produced by the pituitary
gland, a pea-sized gland in the brain that plays an
important role in sexual development.
Option C: Normal growth may occur for the first year,
followed by linear growth thereafter. There is general
agreement that early onset of progressive growth
deceleration is a major characteristic in these children,
even though disagreement exists about the birth length
findings. The clinical data confirm that GH plays an
essential role in early linear growth during infancy.
Option D: Height is affected more profoundly than
weight, contributing to obesity. Weight deceleration is
also present but to a lesser degree. It is possible that
infants with total absence or resistance to GH are
undergrown, whereas other infants with structural
lesions in the hypothalamic-pituitary area have less
severe forms of fetal GH deficiency that do not prevent
attainment of normal birth length.
13. Which type of diabetes mellitus (DM) most likely
results from heterogenous risk factors, making it
preventable?
A. Type 1
B. Type 2
C. Type 1 and 2
D. Gestational diabetes
Type 2 DM is a complex disorder of various causes with
social, behavioral, and environmental risk factors. The
disorder may be prevented by encouraging lifestyle
modification for children at risk. Hyperglycemia results
when there is a relative lack of insulin compared to
glucose in the blood. In type 2 diabetes mellitus, insulin
resistance first leads to increased insulin production by
the beta cells of the pancreas. When the beta cells are
unable to produce enough insulin to maintain
euglycemia, hyperglycemia results.
Option A: Type 1 diabetes is an autoimmune condition
that leads to the destruction of pancreatic beta cells
which in turn causes insufficient insulin production,
resulting in hyperglycemia. Both genetic and
environmental contributions lead to immune-mediated
loss of beta-cell function resulting in hyperglycemia and
life-long insulin dependence.
Option C: With insulin replacement, type 1 diabetes is a
chronic disease requiring intensive effort on the part of
the person with diabetes and caregivers. There is an
emphasis on reducing hyperglycemia while minimizing
the risk of hypoglycemia. The complex balance of
glucose is affected by food, insulin doses, body
stresses, exercise, and dozens of other factors.
Option D: Gestational diabetes etiology is apparently
related to 1) the pancreatic beta-cell dysfunction or the
delayed response of the beta cells to the glycemic
levels, and 2) the marked insulin resistance secondary
to placental hormonal release. The human placental
lactogen is the main hormone related to increased
insulin resistance in GDM.
14. Nurse Dorothy is caring for a child with Cushing’s
syndrome. Which of the following should she include in
the plan of care?
A. Increase fluids to prevent dehydration
B. Encourage a diet high in carbohydrates
C. Monitor weight each day and report for weight loss
D. Encourage a diet high in potassium
The elevation of cortisol level in Cushing’s disease
causes a decrease in the level of potassium, a condition
called hypokalemia. At high levels, cortisol stimulates
the tubules that control the absorption of electrolytes in
the kidneys to excrete more potassium into the urine.
Option A: Too much sodium in the diet promotes fluid
retention and weight gain. There should be adequate
potassium in the diet since the elevation of cortisol level
causes hypokalemia. Limiting fluid intake is important in
preventing circulatory overload.
Option B: Encourage the client to have low sodium and
high potassium diet. Excessive cortisol causes sodium
and water retention, edema, and increased potassium
excretion. Mineralocorticoids regulate sodium and
potassium secretion, and excess levels cause marked
sodium and water retention as well as marked
hypokalemia.
Option C: Assess for any changes in personal
appearance caused by the cortisol excess. These
changes may include fullness and rounding of the face
(moon face), added fat on the back of the neck (buffalo
hump), excessive weight gain, red cheeks (plethora),
increased body and facial hair, and Hyperpigmentation
of skin, hair, and mucous membranes occur as a result
of the increased level of melanocyte-stimulating
hormones and ACTH.
15. Nurse Henry admits a child with suspected type 1
DM; Which of the following questions should the nurse
ask the parents?
A. "Does the child complain of headache?"
B. "How much exercise does the child get?"
C. "Has the child's number and type of bowel
movements changed?"
D. "Has the child experienced nocturia or
bedwetting?"
E. "How much candy and sweets does your child take
daily?"
Bedwetting in children who have previously stayed dry
at night is often an early sign of diabetes. Type 1
diabetes is a disease when the pancreas that produces
insulin and helps get sugars (glucose) into the cells does
not produce insulin. As most children with type 1
diabetes are otherwise healthy, history and physical
health is usually limited to the assessment of pertinent
diabetes care.
Option A: At presentation, children usually have a
history of polyuria, polydipsia, and weight loss for days
to months. If the diagnosis is delayed, there may be
vomiting, lethargy, altered mental status, dehydration,
and acidosis.
Option B: At regular visits, the provider will assess
changes in diabetes status and life circumstances
affecting diabetes management, for example, school
experience, changes in patterns of exercise and diet, the
developmental stage of the child, their participation in
diabetes care tasks, family and home life changes, and
adherence to therapy.
Option C: History and physical assessment also focus
on addressing issues related to glucose monitoring,
insulin delivery (e.g., lipodystrophy, skin tolerance to
medical adhesives on diabetes technology), and
screening for symptoms of associated medical issues
such as thyroid dysfunction or celiac disease.
16. Nurse Bennet is a community nurse practicing
primary prevention for psychiatric disorders in children.
On which of the following risk factors would he focus?
A. Being raised in a single-parent home
B. Family history of mental illness
C. Lack of peer friendship
D. Family culture
Abnormal genes and family history of mental illness
have been implicated in many psychiatric disorders
occurring in children and adolescents. Genes associated
with mental health disorders have been reported to
show high expression throughout the lifespan, beginning
in the 2nd trimester and impacting neurodevelopmental
processes, which may explain the early ages of onset.
Option A: There is no evidence that being raised in a
single-parent home will increase a child’s risk of
developing a psychiatric disorder. Like adults, children
and adolescents vary in temperament. Some are shy
and reticent; others are socially exuberant. Some are
methodical and cautious; others are impulsive and
careless. Whether a child is behaving like a typical child
or has a disorder is determined by the presence of
impairment and the degree of distress related to the
symptoms.
Option C: Children who have problems with peers and
withdraw from social interaction may have a psychiatric
disorder; however, the nurse noting this problem would
be practicing secondary, not primary, prevention.
Children also exist in the context of environmental
stressors such as the COVID-19 pandemic and military
conflict. The resultant disruption of critical routines and
isolation from extended family, peers, teachers, and
cultural and religious groups have a significant impact,
especially on the most vulnerable groups.
Option D: Family culture is not a risk factor unless the
parental behavior is dramatically atypical from the
surrounding culture. Children exist in the context of a
family system, and that system has a profound effect on
children’s symptoms and behaviors; normal children
living in a family troubled by domestic violence and
substance abuse may superficially appear to have one
or more mental disorders.
17. Alexi, who has separation anxiety disorder, has not
attended school for three (3) weeks, and she cries and
exhibits clinging behaviors when her mother encourages
attendance. The priority nursing action by the home-care
psychiatric nurse would be to:
A. Assist the child in returning to school
immediately with family support.
B. Arrange for a home-school teacher to visit for two (2)
weeks
C. Encourage family discussion of various problem
areas.
D. Use play therapy to help the child express her
feelings.
When a child refuses to attend school as part of
separation anxiety disorder, it is important to avoid
reinforcing this behavior. The nurse’s priority would be to
assist the child in returning to school immediately with
support from the family. The goal is to get the child to
school and to teach parents, school employees, and
health care providers to facilitate this.
Option B: Arranging for a home-school teacher would
reinforce the behavior of not attending school. Children
may avoid school to cope with stress or fear for a vast
number of reasons. Management options include
cognitive behavior therapy, educational-support therapy,
pharmacotherapy, and parent-teacher interventions.
Providers may also consider psychoeducational support
for the child and parents.
Option C: Child therapy with parents and school staff
may be indicated if the child’s difficulties include
comorbid psychiatric diagnosis, prolonged school
absence, or deficits in social skills. Behavior treatments
include relaxation training, systematic desensitization
(that is graded exposure to the school environment),
emotive imagery, social skills training, and contingency
management.
Option D: Although the use of play therapy is an
appropriate treatment intervention, the priority is
returning the child to school. Cognitive behavior therapy
(CBT) is a very structured strategy where a therapist
offers specific instructions for children to enable and
gradually increase their exposure to the school
environment. In CBT, children are encouraged to
confront their fears, and they are taught how to modify
negative thoughts.
18. An adolescent with a depressive disorder is more
likely than an adult with the same disorder to exhibit:
A. Negativism and acting out.
B. Sadness and crying.
C. Suicidal thoughts.
D. Weight gain.
Adolescents sometimes demonstrate behavior that is
uncharacteristic of an adult with a psychiatric disorder.
In a depressive disorder, an adolescent’s negativism
and acting out could be signs of depression. Depressed
adolescents have an attentional bias and a memory
bias. They recall more negative and fewer positive
words than a non-depressed adolescent.
Option B: Depressed or irritable mood most of the day,
almost every day, as demonstrated by either subjective
report, for example, the patient feels sad, empty, or
hopeless, or observation made by others, for example,
the patient appears sad.
Option C: Suicidal thoughts are behaviors of both
adolescents and adults. Repeated thoughts of death
(not just fear of dying), recurrent suicidal ideation without
specific plans; suicide attempt; or a definite plan to
commit suicide is also present.
Option D: An adult may experience either weight loss or
weight gain while depressed, whereas an adolescent
may experience weight loss. Failure to make expected
weight gain or remarkable weight loss when not dieting
or a remarkable weight gain, or decrease or increase in
daily appetite is present among depressed adolescents.
19. Nurse Tiffany reinforces the behavioral contract for a
child having difficulty controlling aggressive behaviors in
the psychiatric unit. Which of the following is the best
rationale for this method of treatment?
A. It will assist the child to develop more adaptive
coping methods.
B. It will avoid having the nurse be responsible for
setting the rules.
C. It will maintain the nurse's role in controlling the
child's behavior.
D. It will prevent the child from manipulating the nurse.
Behavioral therapy is employed for the purpose of
developing adaptive behavior that will improve coping.
The nurse works to enhance the child’s self-functioning
and responsibility for his own behavior using appropriate
means to develop better-coping skills.
Option B: The nurse does not avoid setting rules; it is
the responsibility of the nurse to establish and maintain
appropriate limits. The nurse decides which specific
behaviors to select for the behavior contract. When
possible, the nurse should define behavior targets for
the contract in the form of positive, pro-academic, or
pro-social behaviors.
Option C: The behavior contract is a simple positive
reinforcement intervention that is widely used by
teachers to change student behavior. The behavior
contract spells out in detail the expectations of the child
and teacher (and sometimes parents) in carrying out the
intervention plan, making it a useful planning document.
Also, because the child usually has input into the
conditions that are established within the contract for
earning rewards, the student is more likely to be
motivated to abide by the terms of the behavior contract
than if those terms had been imposed by someone else.
Option D: Although reinforcing behavioral contracts will
help prevent manipulative behavior by the child; this is
not the best rationale for using behavioral treatment,
which aims to improve client behavior.
20. The psychiatric nurse is alert to warning signs of
suicide in the adolescent population. From the following
list, select those behaviors that are indicative of
adolescent suicidal thinking. Select all that apply.
A. Giving away prized possessions
B. Associating with friends who are substance abusers
C. Sudden withdrawal from friends and family
D. Having difficulty concentrating on one thing at a time
E. Being easily distracted by environmental events
F. Verbal hints or threats about suicide
These are all warning signs that an adolescent is having
suicidal thoughts. The nurse should directly question
any adolescent about suicide intent when these
indicators are noted. Suicidal ideation sometimes
referred to as suicidal thoughts, describes thoughts,
fantasies, ideas, or images related to committing
suicide. Contrary to common belief, depression and
suicidal thoughts are not limited to adults, but symptoms
and warning signs are often different in teens.
Option A: Giving away belongings when there is no
other logical explanation for why this is being done is a
warning sign that a teen might be suicidal. In the U.S.,
suicide attempts are more common in adolescent girls
than boys. But boys are more likely to die by suicide
than are girls.
Option B: This may indicate that the adolescent has a
problem with substance use, but not necessarily suicide.
They might also be unable to see that they can turn their
lives around — and that suicide is a permanent
response, not a solution, to a temporary problem.
Option C: Don’t dismiss suicidal talk as “typical teen
drama.” If a child is making comments such as “I might
as well kill myself” or “I wish I was dead,” you need to
listen and acknowledge their pain.
Option D: Many teens who attempt or die by suicide
have a mental health condition. As a result, they have
trouble coping with the stress of being a teen, such as
dealing with rejection, failure, breakups, school
difficulties, and family turmoil.
Option E: These are signs of attention deficit
hyperactivity disorder, not suicide. If a teen is thinking
about suicide, he or she is likely displaying warning
signs. Listen to what the child is saying and watch how
he or she is acting. Never shrug off threats of suicide as
teen melodrama.
Option F: Active suicidal ideation is when a teen
experiences persistent thoughts of suicide and
continues to feel hopeless. When the ideation is active,
a teen begins to take steps to carry out a suicide
attempt.
21. A nurse prepares to administer a 3ml injection via
intramuscular injection to a 5-year-old child. The nurse
selects which site to administer the medication?
A. Rectus femoris
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Intramuscular injection sites are chosen based on the
child’s age and muscle development. The ventrogluteal
muscle is the ideal choice to administer 0.5ml-3ml
amount of injection on a 3-12-year-old child. A study
found that the muscle in the ventrogluteal site is
adequately developed, even in infants between the ages
of 1-12 months and that in particular, in children 12-36
months old, the ventrogluteal site is even thicker than
the anterolateral.
Option A: This site only allows 2ml of injection. Do not
use the inner thigh or back of the thigh. Divide the thigh
into thirds; the injection site is in the middle third section.
To inject into the thigh, the needle size must be at least
16 mm long but may need to be longer depending on
the child’s size.
Option B: This allows 0.5-1ml amount of injection. This
is the top, upper part of the arm. Only inject on this site if
the health-care provider instructs that this is an
appropriate injection site for the child. To inject into the
deltoid, the needle size must be 16 mm.
Option D: For most infants, the vastus lateralis muscle
in the anterolateral thigh is the recommended site for
injection because it provides a large muscle mass. The
deltoid muscle is preferred for children aged 3 through
18 years. The vastus lateralis muscle in the anterolateral
thigh is an alternative site if the deltoid sites cannot be
used.
22. A 1-year-old child is diagnosed with scabies. Which
of the following medicines is expected to be prescribed?
A. Permethrin
B. Lindane
C. Both
D. None
Permethrin and Lindane are used against scabies, but
lindane is contraindicated for children below two years
old because of the risk of seizures and neurotoxicity.
Topical permethrin 5% cream is effective and widely
used. The cream is typically applied once a week for two
weeks (a total of 2 treatments). However, this treatment
is occasionally associated with scabies resistance, poor
patient compliance, and rare allergic reactions.
Option B: Other options are topical lindane, 5%
precipitated sulfur, malathion, and topical ivermectin.
Lindane Lotion is contraindicated for premature infants
because their skin may be more permeable than that of
full-term infants and their liver enzymes may not be
sufficiently developed to metabolize Lindane.
Option C: Permethrin has not been approved by the
FDA for use in infants before the age of 2 months, and
limited studies have taken place to assess the use of
this medication in these patients. However, some recent
research suggests that 5% permethrin cream can be
safely used to treat scabies in this infant population.
Option D: For classical scabies, 5% permethrin cream
is applied topically to cool, dry skin from the patient’s
head to the patient’s toes and under the fingernails. The
cream is washed off after 8 to 14 hours and is often
reapplied in the same way one week later.
23. The nurse is giving instructions to a mother with a
child receiving a liquid oral iron supplement. The nurse
tells the mother to:
A. Take it with meals.
B. Mix it with food.
C. Mix it with milk.
D. Administer it using a straw.
An oral liquid iron supplement should be given with a
straw because the medicine will stain the teeth. Mix
each dose in water, fruit juice, or tomato juice. You may
use a drinking tube or straw to help keep the iron
supplement from getting on the teeth.
Option A: Taking it with meals will decrease the
absorption. Iron is best absorbed on an empty stomach
(usually if taken 1 hour before or 2 hours after meals).
Option B: Iron is best absorbed when taken on an
empty stomach, with water or fruit juice (adults: full glass
or 8 ounces; children: ½ glass or 4 ounces), about 1
hour before or 2 hours after meals. However, to lessen
the possibility of stomach upset, iron may be taken with
food or immediately after meals.
Option C: Iron is not mixed with any drink. Avoid taking
antacids, dairy products, tea, or coffee within 2 hours
before or after this medication because they will
decrease its effectiveness.
24. The nurse is reviewing the child’s record who is
scheduled to receive inactivated polio vaccine (IPV).
Which of the following would prompt the nurse to
withhold the administration?
A. History of upper respiratory infections.
B. History of an anaphylactic reaction to
streptomycin.
C. History of recent diarrheal episodes.
D. History of redness at the previous injection site.
digestion, choline that is essential for learning and
memory, and many other important nutrients.
Option D: These are low in potassium. People may
think of ginger ale as another form of soda, but in fact,
this beverage does have some important nutrients,
including calcium, iron, copper, and magnesium, among
others. It is relatively low in calories, but most
manufacturers add sugar to make the drink more
palatable.

Inactivated polio vaccine (IPV) contains a trace amount

of streptomycin, neomycin, and polymyxin. The IPV is
contraindicated in individuals who have had anaphylaxis
following either a previous dose of the vaccine or after
taking streptomycin, polymyxin B, or neomycin, as the
vaccine does contain trace amounts of these
substances.

Option A: Injectable polio vaccine is both safe and

recommended for administration to immunodeficient
individuals and members of their household, as it is not
a live vaccine. Note that the oral polio vaccine is live and
should not be administered to immunocompromised
persons.
Option C: Serious reactions following routine
immunizations are rare. The rate of allergic reaction to
routine vaccines is 1 per million doses administered.
More commonly the recipient may experience a local
vaccine reaction, including erythema or soreness at the
injection site.
Option D: This condition is not contraindicated with this
vaccine. Toxicity related to the oral polio vaccine is not
specific to the formulation, but rather as would be
expected with any live vaccine. As previously stated, live
vaccines are to be avoided in immunocompromised
persons.

25. A nurse is handling a child who is on furosemide

(Lasix) IV infusion. The nurse instructs the mother to
encourage the child to eat which of the following?

A. Apricot and baked potato skin.

B. Bread and butter.
C. Gelatin and Cauliflower.
D. Ginger ale and cereal.

One of the side effects of taking furosemide is

hypokalemia, so a supplemental food rich in potassium
is encouraged. Many fresh fruits and vegetables are rich
in potassium: Bananas, oranges, cantaloupe,
honeydew, apricots, grapefruit (some dried fruits, such
as prunes, raisins, and dates, are also high in
potassium).

Option B: Bread is rich in carbohydrates and butter is

sufficient in fats. Foods that have the highest
concentrations of potassium include cantaloupe,
watermelons, grapefruit, all dried fruit and fruit juices,
avocadoes, tomatoes, potatoes (plain and sweet),
Brussels sprouts, milk, yogurt, lentils, and most nuts
(except peanuts).
Option C: Cauliflower is a cruciferous vegetable that is
naturally high in fiber and B-vitamins. It provides
antioxidants and phytonutrients that can protect against
cancer. It also contains fiber to enhance weight loss and