The nurse is assessing a 4-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Select all that apply.
- Fails to make eye contact
- Flinches when touched on the arm
- History of limited prenatal care and precipitate delivery
- Head circumference has not changed in over 1 year
- Flat facial expressions
1,2,3,5
Which factor, noted by the nurse during the pediatric health history portion of the assessment process, would indicate the child is at risk for attention deficit/hyperactivity disorder (ADHD)?
- Measles, mumps, and rubella vaccine
- Advanced parental age
- Prenatal exposure to smoke
- Immune response
3
Which data, noted by the nurse during the physical assessment, would indicate the need to refer an adolescent client for further treatment due to possible depression? Select all that apply.
- Agoraphobia
- Somatic complaints
- Focus on violence
- Poor self-care
- Poor school performance
3,4,5
Which statement from the parent of a child diagnosed with attention deficit/hyperactivity disorder (ADHD) indicates the need for further education by the nurse?
- “I will develop a reward system for desired behaviors.”
- “I will take my child to the physician every 3 months for a weight and height check.”
- “I will let him do his homework while he is watching his favorite television show.”
- “I will stick to the same routine each day after school.”
3
A child diagnosed with autism spectrum disorder (ASD) is admitted to the hospital with dehydration. Which should the nurse include in the plan of care for this child?
- Discourage the parents from bringing favorite toys from home that might be lost.
- Take the child on a tour of the pediatric unit.
- Assign the child to a single-bed hospital room.
- Take the child to the playroom for arts and crafts.
3
A school-age child is diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. Which term should the nurse use when documenting this child’s disorder in the medical record?
- Dysgraphia
- Dyscalculia
- Dyspraxia
- Dyslexia
3
The nurse is assessing a child with Down syndrome. Which illness should the nurse monitor for due to the increased risk for children with Down syndrome?
- Rheumatic heart disease
- Glomerulonephritis
- Leukemia
- Hepatitis
3
Which children should the nurse identify as exhibiting a delay in meeting developmental milestones? Select all that apply.
- An 18-month-old toddler who is unable to speak in sentences
- A 2-year-old child who is unable to cut with scissors
- A 2-year-old child who cannot recite her phone number
- A 6-year-old child who is unable to sit still for a short story
- A 5-year-old child who is unable to button his shirt
4,5
The nurse is planning care for a school-age child diagnosed with separation anxiety disorder. Which aspects of cognitive-behavior therapy (CBT) should the nurse include in the teaching plan for the child’s family? Select all that apply.
- Self-talking
- Relaxation
- Hypnosis
- Antidepressant medications
- Recognition of feelings
1,2,5
Which information should the nurse include in the teaching plan for the parents of a child who is diagnosed with autism spectrum disorder (ASD) as methods to increase the child’s socialization?
- Create a reward system when the child interacts with a person.
- Punish the child when the child’s social behaviors are inappropriate.
- Use dolls to demonstrate appropriate social interactions to the child.
- Enroll the child in a day care facility to encourage interaction with other children.
1
Which child should the nurse refer for further assessment due to a probable diagnosis for autism spectrum disorder (ASD)?
- A 4-year-old girl who doesn’t make eye contact with mother and resists the mother’s touch
- A 3-year-old boy who joins one group of children, then moves to another group of children without joining their activities
- An 18-month-old child who walks around the area using the furniture to provide balance
- A 6-year-old boy who chatters constantly to anyone who will listen
1
Which activities should the nurse include in the plan of care for a child diagnosed with attention deficit/hyperactivity disorder (ADHD) to improve behavior and learning? Select all that apply.
- Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child
- Placing the child’s desk at the back of the room to reduce distractions
- Developing a consistent routine for the classroom
- Limiting the decorations in the classroom
- Determining areas where the child performs well and using these areas to promote self-esteem
3,4,5
A school-age client presents to the pediatric clinic with a history of abdominal pain 3 to 4 mornings per week over the last 2 months. The mother states the child usually complains on school days and always seems to be better by afternoon. Which mental health disorder does the nurse suspect?
- Separation anxiety
- Depression
- School phobia
- Bipolar disorder
3
Which nursing action assists in the diagnosis of mental health and cognitive disorders that occur during childhood?
- Monitoring vital signs
- Administering prescribed medications
- Conducting a developmental assessment
- Documenting an accurate history and physical
3
The mother of a 22-month-old child states, “My child does not seem to be developing like my sister’s daughter, who is the same age.” Which screening test should the nurse plan to conduct based on the current data?
- Magnetic resonance imaging (MRI) of the head
- An electroencephalogram (EEG)
- A Denver II
- Chromosomal study
3
Which statements should the nurse include in the definition of mental health during a health maintenance fair for pediatric clients? Select all that apply.
- Mental health is the change in thought that occurs during childhood.
- Mental health is foundational to a sense of personal well-being.
- Mental health does not impact physical health.
- Mental health involves successful engagement in activities.
- Mental health changes over time.
2,4
Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with autism spectrum disorder (ASD)? Select all that apply.
- Arm flapping
- Language delays
- Ritualistic behavior
- Impulsive behavior
- Sleep disturbances
1,2,3
Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with attention deficit/ hyperactivity disorder (ADHD)? Select all that apply.
- Arm flapping
- Language delays
- Ritualistic behavior
- Impulsive behavior
- Sleep disturbances
4,5
Which interventions should the nurse include in the plan of care for a child who is diagnosed with an intellectual disability? Select all that apply.
- Providing emotional support to the family
- Maintaining a safe environment for the client
- Educating the family that maintenance of activities of daily living (ADL) is impossible to achieve
- Participating in the individualized education program (IEP) process
- Recommending permanent institutionalization
1,2,4
Which items noted in a pediatric client’s medical record indicate the child may be experiencing a learning disability? Select all that apply.
- Dyslexia
- Dysphagia
- Dyspraxia
- Scoliosis
- Hypotonia
1,3
