Chapter 01: Perspectives of Pediatric Nursing
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is planning a teaching session for parents of preschool children. Which statement ex-
plains why the nurse should include information about morbidity and mortality?
a.
Life span statistics are included in the data.
b.
It explains effectiveness of treatment.
c.
Cost-effective treatment is detailed for the
general population.
d.
High-risk age groups for certain disorders or
hazards are identified.
ANS: D
Analysis of morbidity and mortality data provides the parents with information about which
groups of individuals are at risk for which health problems. Life span statistics is a part of the
mortality data. Treatment modalities and cost are not included in morbidity and mortality data.
DIF: Cognitive Level: Apply
REF: p. 11
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A clinic nurse is planning a teaching session about childhood obesity prevention for parents of
school-age children. The nurse should include which associated risk of obesity in the teaching
plan?
a.
Type I diabetes
b.
Respiratory disease
c.
Celiac disease
d.
Type II diabetes
ANS: D
Childhood obesity has been associated with the rise of type II diabetes in children. Type I diabetes is not associated with obesity and has a genetic component. Respiratory disease is not associated with obesity, and celiac disease is the inability to metabolize gluten in foods and is not associated with obesity.
DIF: Cognitive Level: Apply
REF: p. 2
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is the leading cause of death in infants younger than 1 year?
a.
Congenital anomalies
b.
Sudden infant death syndrome
c.
Respiratory distress syndrome
d.
Bacterial sepsis of the newborn
ANS: A
Congenital anomalies account for 20.1% of deaths in infants younger than 1 year. Sudden infant
death syndrome accounts for 8.2% of deaths in this age group. Respiratory distress syndrome accounts for 3.4% of deaths in this age group. Infections specific to the perinatal period account for
2.7% of deaths in this age group.
DIF: Cognitive Level: Remember
REF: p. 6
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which leading cause of death topic should the nurse emphasize to a group of African-American
boys ranging in age from 15 to 19 years?
a.
b.
c.
d.
Suicide
Cancer
Firearm homicide
Occupational injuries
ANS: C
Firearm homicide is the second overall cause of death in this age group and the leading cause of
death in African-American males. Suicide is the third-leading cause of death in this population.
Cancer, although a major health problem, is the fourth-leading cause of death in this age group.
Occupational injuries do not contribute to a significant death rate for this age group.
DIF: Cognitive Level: Understand
REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which is the major cause of death for children older than 1 year?
a.
Cancer
b.
Heart disease
c.
Unintentional injuries
d.
Congenital anomalies
ANS: C
Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. Congenital anomalies are the leading cause of death in those younger than 1 year. Cancer
ranks either second or fourth, depending on the age group, and heart disease ranks fifth in the
majority of the age groups.
DIF: Cognitive Level: Remember
REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which is the leading cause of death from unintentional injuries for females ranging in age from 1
to 14?
a.
b.
c.
d.
Mechanical suffocation
Drowning
Motor vehicle–related fatalities
Fire- and burn-related fatalities
ANS: C
Motor vehicle–related fatalities are the leading cause of death for females ranging in age from 1
to 14, either as passengers or as pedestrians. Mechanical suffocation is fourth or fifth, depending
on the age. Drowning is the second- or third-leading cause of death, depending on the age. Fireand burn-related fatalities are the second-leading cause of death.
DIF: Cognitive Level: Remember
REF: p. 3
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which factor most impacts the type of injury a child is susceptible to, according to the child’s
age?
a.
b.
c.
d.
Physical health of the child
Developmental level of the child
Educational level of the child
Number of responsible adults in the home
ANS: B
The child’s developmental stage determines the type of injury that is likely to occur. The child’s
physical health may facilitate the child’s recovery from an injury but does not impact the type of
injury. Educational level is related to developmental level, but it is not as important as the child’s
developmental level in determining the type of injury. The number of responsible adults in the
home may affect the number of unintentional injuries, but the type of injury is related to the
child’s developmental stage.
DIF: Cognitive Level: Understand
REF: p. 3
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which is now referred to as the “new morbidity”?
a.
Limitations in the major activities of daily
b.
c.
d.
living
Unintentional injuries that cause chronic
health problems
Discoveries of new therapies to treat health
problems
Behavioral, social, and educational problems
that alter health
ANS: D
The new morbidity reflects the behavioral, social, and educational problems that interfere with
the child’s social and academic development. It is currently estimated that the incidence of these
issues is from 5% to 30%. Limitations in major activities of daily living and unintentional injuries that result in chronic health problems are included in morbidity data. Discovery of new
therapies would be reflected in changes in morbidity data over time.
DIF: Cognitive Level: Remember
REF: p. 2
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. A nurse on a pediatric unit is practicing family-centered care. Which is most descriptive of the
care the nurse is delivering?
a.
b.
c.
d.
Taking over total care of the child to reduce
stress on the family
Encouraging family dependence on health
care systems
Recognizing that the family is the constant in
a child’s life
Excluding families from the decision-making
process
ANS: C
The three key components of family-centered care are respect, collaboration, and support. Family-centered care recognizes the family as the constant in the child’s life. Taking over total care
does not include the family in the process and may increase stress instead of reducing stress. The
family should be enabled and empowered to work with the health care system. The family is expected to be part of the decision-making process.
DIF: Cognitive Level: Remember
REF: p. 7
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. The nurse is preparing an in-service education to staff about atraumatic care for pediatric pa-
tients. Which intervention should the nurse include?
a.
Prepare the child for separation from parents
during hospitalization by reviewing a video.
b.
Prepare the child before any unfamiliar treat
ment or procedure by demonstrating on a
stuffed animal.
c.
Help the child accept the loss of control asso
ciated with hospitalization.
d.
Help the child accept pain that is connected
with a treatment or procedure.
ANS: B
Preparing the child for any unfamiliar treatments, controlling pain, allowing privacy, providing
play activities for expression of fear and aggression, providing choices, and respecting cultural
differences are components of atraumatic care. In the provision of atraumatic care, the separation
of child from parents during hospitalization is minimized. The nurse should promote a sense of
control for the child. Preventing and minimizing bodily injury and pain are major components of
atraumatic care.
DIF: Cognitive Level: Understand
REF: p. 8
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
11. Which is most suggestive that a nurse has a nontherapeutic relationship with a patient and fam-
ily?
a.
b.
c.
d.
Staff is concerned about the nurse’s actions
with the patient and family.
Staff assignments allow the nurse to care for
same patient and family over an extended
time.
Nurse is able to withdraw emotionally when
emotional overload occurs but still remains
committed.
Nurse uses teaching skills to instruct patient
and family rather than doing everything for
them.
ANS: A
An clue to a nontherapeutic staff-patient relationship is concern of other staff members. Allowing
the nurse to care for the same patient over time would be therapeutic for the patient and family.
Nurses who are able to somewhat withdraw emotionally can protect themselves while providing
therapeutic care. Nurses using teaching skills to instruct patient and family will assist in transitioning the child and family to self-care.
DIF: Cognitive Level: Analyze
REF: p. 8
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
12. Which is most descriptive of clinical reasoning?
a.
A simple developmental process
b.
Purposeful and goal-directed
c.
Based on deliberate and irrational thought
d.
Assists individuals in guessing what is most
appropriate
ANS: B
Clinical reasoning is a complex, developmental process based on rational and deliberate thought.
Clinical reasoning is not a developmental process. Clinical reasoning is based on rational and deliberate thought. Clinical reasoning is not a guessing process.
DIF: Cognitive Level: Understand
REF: p. 10
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
13. A nurse makes the decision to apply a topical anesthetic to a child’s skin before drawing blood.
Which ethical principle is the nurse demonstrating?
Autonomy
Beneficence
Justice
Truthfulness
a.
b.
c.
d.
ANS: B
Beneficence is the obligation to promote the patient’s well-being. Applying a topical anesthetic
before drawing blood promotes reducing the discomfort of the venipuncture. Autonomy is the
patient’s right to be self-governing. Justice is the concept of fairness. Truthfulness is the concept
of honesty.
DIF: Cognitive Level: Understand
REF: p. 10
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity
14. Which action by the nurse demonstrates use of evidence-based practice (EBP)?
a.
Gathering equipment for a procedure
b.
Documenting changes in a patient’s status
c.
Questioning the use of daily central line
d.
dressing changes
Clarifying a physician’s prescription for mor
phine
ANS: C
The nurse who questions the daily central line dressing change is ascertaining whether clinical
interventions result in positive outcomes for patients. This demonstrates EBP, which implies
questioning why something is effective and whether a better approach exists. Gathering equipment for a procedure and documenting changes in a patient’s status are practices that follow established guidelines. Clarifying a physician’s prescription for morphine constitutes safe nursing
care.
DIF: Cognitive Level: Apply
REF: p. 10
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
15. A nurse is admitting a toddler to the hospital. The toddler is with both parents and is currently sit-
ting comfortably on a parent’s lap. The parents state they will need to leave for a brief period.
Which type of nursing diagnosis should the nurse formulate for this child?
a.
Risk for anxiety
b.
Anxiety
c.
Readiness for enhanced coping
d.
Ineffective coping
ANS: A
A potential problem is categorized as a risk. The toddler has a risk to become anxious when the
parents leave. Nursing interventions will be geared toward reducing the risk. The child is not
showing current anxiety or ineffective coping. The child is not at a point for readiness for enhanced coping, especially because the parents will be leaving.
DIF: Cognitive Level: Remember
REF: p. 11
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A child has a postoperative appendectomy incision covered by a dressing. The nurse has just
completed a prescribed dressing change for this child. Which description is an accurate documentation of this procedure?
a.
Dressing change to appendectomy incision
b.
c.
d.
completed, child tolerated procedure well,
parent present
No complications noted during dressing
change to appendectomy incision
Appendectomy incision non-reddened, sutures intact, no drainage noted on old dressing, new dressing applied, procedure tolerated
well by child
No changes to appendectomy incisional area,
dressing changed, child complained of pain
during procedure, new dressing clean, dry and
intact
ANS: C
The nurse should document assessments and reassessments. Appearance of the incision described
in objective terms should be included during a dressing change. The nurse should document patient’s response and the outcomes of the care provided. In this example, these include drainage
on the old dressing, the application of the new dressing, and the child’s response. The other statements partially fulfill the requirements of documenting assessments and reassessments, patient’s
response, and outcome, but do not include all three.
DIF: Cognitive Level: Analyze
REF: p. 12
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
17. A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is
the priority for this class?
a.
b.
c.
d.
Appropriate use of car seat restraints
Safety crossing the street
Helmet use when riding a bicycle
Poison control numbers
ANS: A
Motor vehicle accidents (MVAs) continue to be the most common cause of death in children
older than 1 year, therefore the priority topic is appropriate use of car seat restraints. Safety
crossing the street and bicycle helmet use are topics that should be included for preschool parents
but are not priorities for parents of toddlers. Information about poison control is important for
parents of toddlers and would be a safety topic to include but is not the priority over appropriate
use of car seat restraints.
DIF: Cognitive Level: Apply
REF: p. 3
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. A nurse is collecting subjective and objective information about target populations to diagnose
problems based on community needs. This describes which step in the community nursing
process?
a.
Planning
b.
c.
d.
Diagnosis
Assessment
Establishing objectives
ANS: C
The nursing process stages are similar, whether the client is one child or a population of children.
The assessment phase of the nursing process focuses on collecting subjective and objective data.
Planning is the development of community-centered goals and objectives. Diagnosis is the identification of problems specific to the community.
DIF: Cognitive Level: Understand
REF: p. 11
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
19. A nurse is establishing several health programs, such as bicycle safety, to improve the health sta-
tus of a target population. This describes which step in the community nursing process?
Planning
Evaluation
Assessment
Implementation
a.
b.
c.
d.
ANS: D
The nurse working with the community to put into practice a program to reach community goals
is the implementation phase of the community nursing process. Planning involves designing the
program to meet community-centered goals. The evaluation stage would determine the effectiveness of the program. During the assessment phase, the nurse would identify the resources necessary and the barriers that would interfere with implementation.
DIF: Cognitive Level: Understand
REF: p. 11
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
20. A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of
prevention is the nurse demonstrating?
a.
b.
c.
d.
Primary
Secondary
Tertiary
Health promotion
ANS: B
Secondary prevention focuses on screening and early diagnosis of disease. Vision and hearing
testing are screening tests to detect problems. Primary prevention focuses on health promotion
and prevention of disease or injury. Tertiary prevention focuses on optimizing function for children with a disability or chronic disease. Health promotion is focused on preventing disease or
illness.
DIF: Cognitive Level: Understand
REF: p. 2
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
21. The home health nurse asks a child’s mother many questions as part of the assessment. The
mother answers many questions, then stops and says, “I don’t know why you ask me all this.
Who gets to know this information?” The nurse should take which action?
a.
Determine why the mother is so suspicious.
b.
Determine what the mother does not want to
tell.
c.
Explain who will have access to the informa
tion.
d.
Explain that everything is confidential and
that no one else will know what is said.
ANS: C
Communication with the family should not be invasive. The nurse needs to explain the importance of collecting the information, its applicability to the child’s care, and who will have access
to the information. The mother is not being suspicious and is not necessarily withholding important information. She has a right to understand how the information she provides will be used.
The nurse will need to share, through both oral and written communication, clinically relevant
information with other involved health professionals.
DIF: Cognitive Level: Apply
REF: p. 9
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
22. When communicating with other professionals, what is important for the nurse to do?
a.
Ask others what they want to know.
b.
Share everything known about the family.
c.
Restrict communication to clinically relevant
d.
information.
Recognize that confidentiality is not possible.
ANS: C
The nurse will need to share, through both oral and written communication, clinically relevant
information with other involved health professionals. Asking others what they want to know and
sharing everything known about the family is inappropriate. Patients have a right to confidentiality. The nurse is not permitted to share information about clients, except clinically relevant information that pertains to the child’s care. Confidentiality permits the disclosure of information to
other health professionals on a need-to-know basis.
DIF: Cognitive Level: Apply
REF: p. 9
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
23. A nurse manager at a home-care agency is planning a continuing education program for the
home-care staff nurses. Which type of continuing education program should the nurse manager
plan?
a.
On-line training modules
b.
A structured written teaching module each
nurse completes individually
c.
d.
A workshop training day, with a professional
speaker, where nurses can interact with each
other
One-on-one continuing education training
with each nurse
ANS: C
Because of the unique practice environment of home care nurses, it is important for an agency to
facilitate sharing among peers to decrease work-related stress, increase job satisfaction, and support high-quality patient care. On-line training, written teaching modules, and one-on-one training would not allow for any sharing with peers.
DIF: Cognitive Level: Apply
REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. Which behaviors by the nurse indicate a therapeutic relationship with children and families? (Se-
lect all that apply.)
a.
b.
c.
d.
e.
Spending off-duty time with children and
families
Asking questions if families are not participating in the care
Clarifying information for families
Buying toys for a hospitalized child
Learning about the family’s religious preferences
ANS: B, C, E
Asking questions if families are not participating in the care, clarifying information for families,
and learning about the family’s religious preferences are positive actions and foster therapeutic
relationships with children and families. Spending off-duty time with children and families and
buying toys for a hospitalized child are negative actions and indicate overinvolvement with children and families, which is nontherapeutic.
DIF: Cognitive Level: Understand
REF: p. 8
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
2. Which behaviors by the nurse indicate therapeutic nurse-family boundaries? (Select all that ap-
ply.)
a.
b.
c.
d.
Nurse visits family on days off.
House rules are negotiated.
Nurse buys child expensive gifts.
Communication is open and two-way.
ANS: B, D
A home care nurse can establish therapeutic nurse-family boundaries by negotiating house rules
and ensuring that communication is open and two-way. Visiting the family of off-duty days and
buying expensive gifts for the child would be boundary crossing and nontherapeutic.
DIF: Cognitive Level: Analyze
REF: p. 8
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
OTHER
1. A nurse is formulating a clinical question for evidence-based practice. Place in order the steps the
nurse should use to clarify the scope of the problem and clinical topic of interest. Begin with the
first step of the process and proceed ordering the steps ending with the final step of the process.
Provide answer as lowercase letters separated by commas (e.g., a, b, c, d, e).
a. Intervention
b. Outcome
c. Population
d. Time
e. Control
ANS:
c, a, e, b, d
When formulating a clinical question for evidence-based practice, the nurse should follow a concise, organized way that allows for clear answers. Good clinical questions should be asked in the
PICOT (population, intervention, control, outcome, time) format to assist with clarity and literature searching. PICOT questions assist with clarifying the scope of the problem and clinical topic
of interest.
DIF: Cognitive Level: Understand
REF: p. 10
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 02: Family, Social, Cultural, and Religious Influences on Child Health
Promotion
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is selecting a family theory to assess a patient’s family dynamics. Which family
theory best describes a series of tasks for the family throughout its life span?
Interactional theory
Developmental systems theory
Structural-functional theory
Duvall’s developmental theory
a.
b.
c.
d.
ANS: D
Duvall’s developmental theory describes eight developmental tasks of the family throughout
its life span. Interactional theory and structural-functional theory are not family theories.
Developmental systems theory is an outgrowth of Duvall’s theory. The family is described as
a small group, a semiclosed system of personalities that interact with the larger cultural
system. Changes do not occur in one part of the family without changes in others.
DIF: Cognitive Level: Understand
REF: p. 17
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which family theory explains how families react to stressful events and suggests factors that
promote adaptation to these events?
Interactional theory
Developmental systems theory
Family stress theory
Duvall’s developmental theory
a.
b.
c.
d.
ANS: C
Family stress theory explains the reaction of families to stressful events. In addition, the
theory helps suggest factors that promote adaptation to the stress. Stressors, both positive and
negative, are cumulative and affect the family. Adaptation requires a change in family
structure or interaction. Interactional theory is not a family theory. Interactions are the basis
of general systems theory. Developmental systems theory is an outgrowth of Duvall’s theory.
The family is described as a small group, a semiclosed system of personalities that interact
with the larger cultural system. Changes do not occur in one part of the family without
changes in others. Duvall’s developmental theory describes eight developmental tasks of the
family throughout its life span.
DIF: Cognitive Level: Understand
REF: p. 16
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is the term for a family in which the paternal grandmother, the parents, and two minor
children live together?
a. Blended
b. Nuclear
c. Binuclear
d. Extended
ANS: D
An extended family contains at least one parent, one or more children, and one or more
members (related or unrelated) other than a parent or sibling. A blended family contains at
least one stepparent, step-sibling, or half-sibling. The nuclear family consists of two parents
and their children. No other relatives or nonrelatives are present in the household. In
binuclear families, parents continue the parenting role while terminating the spousal unit. For
example, when joint custody is assigned by the court, each parent has equal rights and
responsibilities for the minor child or children.
DIF: Cognitive Level: Remember
REF: p. 18
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is assessing a family’s structure. Which describes a family in which a mother, her
children, and a stepfather live together?
Blended
Nuclear
Binuclear
Extended
a.
b.
c.
d.
ANS: A
A blended family contains at least one stepparent, step-sibling, or half-sibling. The nuclear
family consists of two parents and their children. No other relatives or nonrelatives are
present in the household. In binuclear families, parents continue the parenting role while
terminating the spousal unit. For example, when joint custody is assigned by the court, each
parent has equal rights and responsibilities for the minor child or children. An extended
family contains at least one parent, one or more children, and one or more members (related
or unrelated) other than a parent or sibling.
DIF: Cognitive Level: Understand
REF: p. 18
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Parents of a firstborn child are asking whether it is normal for their child to be extremely
competitive. The nurse should respond to the parents that studies about the ordinal position of
children suggest that firstborn children tend to:
a. be praised less often.
b. be more achievement oriented.
c. be more popular with the peer group.
d. identify with peer group more than parents.
ANS: B
Firstborn children, like only children, tend to be more achievement oriented. Being praised
less often, being more popular with the peer group, and identifying with peer groups more
than parents are characteristics of later-born children.
DIF: Cognitive Level: Apply
REF: p. 29
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. The nurse is teaching a group of new parents about the experience of role transition. Which
statement by a parent would indicate a correct understanding of the teaching?
a. “My marital relationship can have a positive or negative effect on the role
transition.”
b. “If an infant has special care needs, the parents’ sense of confidence in their new
role is strengthened.”
c. “Young parents can adjust to the new role easier than older parents.”
d. “A parent’s previous experience with children makes the role transition more
difficult.”
ANS: A
If parents are supportive of each other, they can serve as positive influences on establishing
satisfying parental roles. When marital tensions alter caregiving routines and interfere with
the enjoyment of the infant, then the marital relationship has a negative effect. Infants with
special care needs can be a significant source of added stress. Older parents are usually more
able to cope with the greater financial responsibilities, changes in sleeping habits, and
reduced time for each other and other children. Parents who have previous experience with
parenting appear more relaxed, have less conflict in disciplinary relationships, and are more
aware of normal growth and development.
DIF: Cognitive Level: Understand
REF: p. 17
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. When assessing a family, the nurse determines that the parents exert little or no control over
their children. What is this style of parenting called?
Permissive
Dictatorial
Democratic
Authoritarian
a.
b.
c.
d.
ANS: A
Permissive parents avoid imposing their own standards of conduct and allow their children to
regulate their own activity as much as possible. The parents exert little or no control over
their children’s actions. Dictatorial or authoritarian parents attempt to control their children’s
behavior and attitudes through unquestioned mandates. They establish rules and regulations
or standards of conduct that they expect to be followed rigidly and unquestioningly.
Democratic parents combine permissive and dictatorial styles. They direct their children’s
behavior and attitudes by emphasizing the reasons for rules and negatively reinforcing
deviations. They respect the child’s individual nature.
DIF: Cognitive Level: Remember
REF: p. 20
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
8. When discussing discipline with the mother of a 4-year-old child, the nurse should include
which instruction?
Children as young as 4 years old rarely need to be punished.
Parental control should be consistent.
Withdrawal of love and approval is effective at this age.
One should expect rules to be followed rigidly and unquestioningly.
a.
b.
c.
d.
ANS: B
For effective discipline, parents must be consistent and must follow through with agreed-on
actions. Realistic goals should be set for this age group. Parents should structure the
environment to prevent unnecessary difficulties. Requests for behavior change should be
phrased in a positive manner to provide direction for the child. Withdrawal of love and
approval is never appropriate or effective. Discipline strategies should be appropriate to the
child’s age, temperament, and severity of the misbehavior. Following rules rigidly and
unquestioningly is beyond the developmental capabilities of a 4-year-old.
DIF: Cognitive Level: Apply
REF: p. 20
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Which is most characteristic of the physical punishment of children, such as spanking?
a. Psychological impact is usually minimal.
b. Children rarely become accustomed to spanking.
c. Children’s development of reasoning increases.
d. Misbehavior is likely to occur when parents are not present.
ANS: D
Through the use of physical punishment, children learn what they should not do. When
parents are not around, it is more likely that children will misbehave because they have not
learned to behave well for their own sake, but rather out of fear of punishment. Spanking can
cause severe physical and psychological injury and interfere with effective parent-child
interaction. Children do become accustomed to spanking, requiring more severe corporal
punishment each time. The use of corporal punishment may interfere with the child’s
development of moral reasoning.
DIF: Cognitive Level: Understand
REF: p. 20
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. A 3-year-old girl was adopted immediately after birth. The parents have just asked the nurse
how they should tell the child that she is adopted. Which guidelines concerning adoption
should the nurse use in planning a response?
a. Telling the child is an important aspect of their parental responsibilities.
b. The best time to tell the child is between ages 7 and 10 years.
c. It is not necessary to tell the child who was adopted so young.
d. It is best to wait until the child asks about it.
ANS: A
It is important for the parents not to withhold information about the adoption from the child.
It is an essential component of the child’s identity. There is no recommended best time to tell
children. It is believed that children should be told young enough so they do not remember a
time when they did not know. It should be done before the children enter school to keep third
parties from telling the children before the parents have had the opportunity.
DIF: Cognitive Level: Understand
REF: p. 22
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
11. A parent of a school-age child is going through a divorce. The parent tells the school nurse
the child has not been doing well in school and sometimes has trouble sleeping. The nurse
should recognize this as which implication?
a. Indication of maladjustment
b. Common reaction to divorce
c. Lack of adequate parenting
d. Unusual response that indicates need for referral
ANS: B
Parental divorce affects school-age children in many ways. In addition to difficulties in
school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of
appetite, and sleep disorders. This is not an indication of maladjustment, suggestive of lack of
adequate parenting, or an unusual response that indicates need for referral in school-age
children after parental divorce.
DIF: Cognitive Level: Apply
REF: p. 24
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
12. A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, “I
want to go back to work, but I don’t want Eric to suffer because I’ll have less time with him.”
The nurse’s most appropriate answer would be which statement?
a. “I’m sure he’ll be fine if you get a good babysitter.”
b. “You will need to stay home until Eric starts school.”
c. “You should go back to work so Eric will get used to being with others.”
d. “Let’s talk about the child care options that will be best for Eric.”
ANS: D
Let’s talk about the child care options that will be best for Eric is an open-ended statement
that will assist the mother in exploring her concerns about what is best for both her and Eric.
I’m sure he’ll be fine if you get a good babysitter, You will need to stay home until Eric starts
school, and You should go back to work so Eric will get used to being with others are
directive statements. They do not address the effect of her working on Eric.
DIF: Cognitive Level: Apply
REF: p. 27
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
13. Which term best describes a group of people who share a set of values, beliefs, practices,
social relationships, law, politics, economics, and norms of behavior?
a. Race
b. Culture
c. Ethnicity
d. Social group
ANS: B
Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides
the outlook and decisions of a group of people. A culture is composed of individuals who
share a set of values, beliefs, and practices that serve as a frame of reference for individual
perceptions and judgments. Race is defined as a division of humankind possessing traits that
are transmissible by descent and are sufficient to characterize it as a distinct human type.
Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic
heritage. A social group consists of systems of roles carried out in groups. Examples of
primary social groups include the family and peer groups.
DIF: Cognitive Level: Remember
REF: p. 29
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
14. Which term best describes the emotional attitude that one’s own ethnic group is superior to
others?
a. Culture
b. Ethnicity
c. Superiority
d. Ethnocentrism
ANS: D
Ethnocentrism is the belief that one’s way of living and behaving is the best way. This
includes the emotional attitude that the values, beliefs, and perceptions of one’s ethnic group
are superior to those of others. Culture is a pattern of assumptions, beliefs, and practices that
unconsciously frames or guides the outlook and decisions of a group of people. A culture is
composed of individuals who share a set of values, beliefs, and practices that serves as a
frame of reference for individual perception and judgments. Ethnicity is an affiliation of a set
of persons who share a unique cultural, social, and linguistic heritage. Superiority is the state
or quality of being superior; it does not include ethnicity.
DIF: Cognitive Level: Understand
REF: p. 30
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. Dunst, Trivette, and Deal identified the qualities of strong families that help them function
effectively. Which qualities are included? (Select all that apply.)
a. Ability to stay connected without spending time together
b. Clear set of family values, rules, and beliefs
c. Adoption of one coping strategy that always promotes positive functioning in
dealing with life events
d. Sense of commitment toward growth of individual family members as opposed to
that of the family unit
e. Ability to engage in problem-solving activities
f. Sense of balance between the use of internal and external family resources
ANS: B, E, F
A clear set of family rules, values, and beliefs that establishes expectations about acceptable
and desired behavior is one of the qualities of strong families that help them function
effectively. Strong families also are able to engage in problem-solving activities and to find a
balance between internal and external forces. Strong families have a sense of congruence
among family members regarding the value and importance of assigning time and energy to
meet needs. Strong families also use varied coping strategies. The sense of commitment is
toward the growth and well-being of individual family members, as well as the family unit.
DIF: Cognitive Level: Understand
REF: p. 19
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse is conducting a teaching session on the use of time-out as a discipline measure to
parents of toddlers. Which are correct strategies the nurse should include in the teaching
session? (Select all that apply.)
a. Time-out as a discipline measure cannot be used when in a public place.
b. A rule for the length of time-out is 1 minute per year.
c. When the child misbehaves, one warning should be given.
d. The area for time-out can be in the family room where the child can see the
television.
e. When the child is quiet for the specified time, he or she can leave the room.
ANS: B, C, E
A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an
audible bell to record the time rather than a watch. When the child misbehaves, one warning
should be given. When the child is quiet for the duration of the time, he or she can then leave
the room. Time-out can be used in public places and the parents should be consistent on the
use of time-out. Implement time-out in a public place by selecting a suitable area or explain
to children that time-out will be spent immediately on returning home. The time-out should
not be spent in an area from which the child can view the television. Select an area for timeout that is safe, convenient, and unstimulating but where the child can be monitored, such as
the bathroom, hallway, or laundry room.
DIF: Cognitive Level: Apply
REF: p. 21
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Divorced parents of a preschool child are asking whether their child will display any feelings
or behaviors related to the effect of the divorce. The nurse is correct when explaining that the
parents should be prepared for which types of behaviors? (Select all that apply.)
a. Displaying fears of abandonment
b. Verbalizing that he or she “is the reason for the divorce”
c. Displaying fear regarding the future
d. Ability to disengage from the divorce proceedings
e. Engaging in fantasy to understand the divorce
ANS: A, B, E
A child 3 to 5 years of age (preschool) may display fears of abandonment, verbalize feelings
that he or she is the reason for the divorce, and engage in fantasy to understand the divorce.
He or she would not be displaying fear regarding the future until school age, and the ability to
disengage from the divorce proceedings would be characteristic of an adolescent.
DIF: Cognitive Level: Apply
REF: p. 24
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Teaching and Learning
COMPLETION
1. A nurse is admitting a child, in foster care, to the hospital. The nurse recognizes that foster
parents care for the child _____ hours a day. (Record your answer as a whole number.)
ANS:
24
The term foster care is defined as 24-hour substitute care for children outside of their own
homes.
DIF: Cognitive Level: Understand
REF: p. 27
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 03: Developmental and Genetic Influences on Child Health Promotion
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. An infant gains head control before sitting unassisted. The nurse recognizes that this is which
type of development?
Cephalocaudal
Proximodistal
Mass to specific
Sequential
a.
b.
c.
d.
ANS: A
The pattern of development that is head-to-tail, or cephalocaudal, direction is described by an
infant’s ability to gain head control before sitting unassisted. The head end of the organism
develops first and is large and complex, whereas the lower end is smaller and simpler, and
development takes place at a later time. Proximodistal, or near to far, is another pattern of
development. Limb buds develop before fingers and toes. Postnatally, the child has control of
the shoulder before achieving mastery of the hands. Mass to specific is not a specific pattern
of development. In all dimensions of growth, a definite, sequential pattern is followed.
DIF: Cognitive Level: Understand
REF: p. 38
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which refers to those times in an individual’s life when he or she is more susceptible to
positive or negative influences?
a. Sensitive period
b. Sequential period
c. Terminal points
d. Differentiation points
ANS: A
Sensitive periods are limited times during the process of growth when the organism will
interact with a particular environment in a specific manner. These times make the organism
more susceptible to positive or negative influences. The sequential period, terminal points,
and differentiation points are developmental times that do not make the organism more
susceptible to environmental interaction.
DIF: Cognitive Level: Remember
REF: p. 39
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. An infant who weighs 7 pounds at birth would be expected to weigh how many pounds at age
1 year?
a. 14
b. 16
c. 18
d. 21
ANS: D
In general, birth weight triples by the end of the first year of life. For an infant who was 7
pounds at birth, 21 pounds would be the anticipated weight at the first birthday; 14, 16, or 18
pounds is below what would be expected for an infant with a birth weight of 7 pounds.
DIF: Cognitive Level: Understand
REF: p. 41
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. By what age does birth length usually double?
a. 1 year
b. 2 years
c. 4 years
d. 6 years
ANS: C
Linear growth or height occurs almost entirely as a result of skeletal growth and is considered
a stable measurement of general growth. On average, most children have doubled their birth
length at age 4 years. One and 2 years are too young for doubling of length. Most children
will have achieved the doubling by age 4 years.
DIF: Cognitive Level: Remember
REF: p. 41
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Parents of an 8-year-old child ask the nurse how many inches their child should grow each
year. The nurse bases the answer on the knowledge that after age 7 years, school-age children
usually grow what number of inches per year?
a. 1
b. 2
c. 3
d. 4
ANS: B
The growth velocity after age 7 years is approximately 5 cm (2 inches) per year. One inch is
too small an amount. Three and 4 inches are greater than the average yearly growth after age
7 years.
DIF: Cognitive Level: Apply
REF: p. 41
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Parents express concern that their pubertal daughter is taller than the boys in her class. The
nurse should respond with which statement regarding how the onset of pubertal growth spurt
compares in girls and boys?
a. It occurs earlier in boys.
b. It occurs earlier in girls.
c. It is about the same in both boys and girls.
d. In both boys and girls, the pubertal growth spurt depends on growth in infancy.
ANS: B
Usually, the pubertal growth spurt begins earlier in girls. It typically occurs between the ages
of 10 and 14 years for girls and 11 and 16 years for boys. The average earliest age at onset is
1 year earlier for girls. There does not appear to be a relation to growth during infancy.
DIF: Cognitive Level: Apply
REF: p. 41
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. A 13-year-old girl asks the nurse how much taller she will get. She has been growing about 2
inches per year but grew 4 inches this past year. Menarche recently occurred. The nurse
should base her response on which statement?
a. Growth cannot be predicted.
b. Pubertal growth spurt lasts about 1 year.
c. Mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.
ANS: D
At the time of the beginning of menstruation or the skeletal age of 13 years, most girls have
grown to about 95% of their adult height. They may have some additional growth (5%) until
the epiphyseal plates are closed. Although growth cannot be definitively predicted, on
average, 95% of adult height has been reached with the onset of menstruation. Pubertal
growth spurt lasts about 1 year does not address the girl’s question. Young women usually
will grow approximately 5% more after the onset of menstruation.
DIF: Cognitive Level: Apply
REF: p. 41
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. How is a child’s skeletal age best determined?
a. Assessment of dentition
b. Assessment of height over time
c. Facial bone development
d. Radiographs of the hand and wrist
ANS: D
The most accurate measure of skeletal age is radiologic examinations of the growth plates.
These are the epiphyseal cartilage plates. Radiographs of the hand and wrist provide the most
useful screening to determine skeletal age. Age of tooth eruption has considerable variation in
children. It would not be a good determinant of skeletal age. Assessment of height over time
will provide a record of the child’s height but not skeletal age. Facial bone development will
not reflect the child’s skeletal age, which is determined by radiographic assessment.
DIF: Cognitive Level: Remember
REF: p. 41
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Trauma to which site can result in a growth problem for children’s long bones?
a. Matrix
b. Connective tissue
c. Calcified cartilage
d. Epiphyseal cartilage plate
ANS: D
The epiphyseal cartilage plate is the area of active growth. Bone injury at the epiphyseal plate
can significantly affect subsequent growth and development. Trauma or infection can result
in deformity. The matrix, connective tissue, and calcified cartilage are not areas of active
growth. Trauma in these sites will not result in growth problems for the long bones.
DIF: Cognitive Level: Comprehend
REF: p. 41
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. A nurse has completed a teaching session for adolescents regarding lymphoid tissue growth.
Which statement, by the adolescents, indicates understanding of the teaching?
a. The tissue reaches adult size by age 1 year.
b. The tissue quits growing by 6 years of age.
c. The tissue is poorly developed at birth.
d. The tissue is twice the adult size by ages 10 to 12 years.
ANS: D
Lymphoid tissue continues growing until it reaches maximal development at ages 10 to 12
years, which is twice its adult size. A rapid decline in size occurs until it reaches adult size by
the end of adolescence. The tissue reaches adult size at 6 years of age but continues to grow.
The tissue is well developed at birth.
DIF: Cognitive Level: Analyze
REF: p. 42
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Which statement is true about the basal metabolic rate (BMR) in children?
a. It is reduced by fever.
b. It is slightly higher in boys than in girls at all ages.
c. It increases with age of child.
d. It decreases as proportion of surface area to body mass increases.
ANS: B
The BMR is the rate of metabolism when the body is at rest. At all ages, the rate is slightly
higher in boys than in girls. The rate is increased by fever. The BMR is highest in infancy and
then closely relates to the proportion of surface area to body mass. As the child grows, the
proportion decreases progressively to maturity.
DIF: Cognitive Level: Understand
REF: p. 42
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
12. A mother reports that her 6-year-old child is highly active, irritable, and irregular in habits
and that the child adapts slowly to new routines, people, or situations. How should the nurse
chart this type of temperament?
a. Easy
b. Difficult
c. Slow-to-warm-up
d. Fast-to-warm-up
ANS: B
Being highly active, irritable, irregular in habits, and adapting slowly to new routines, people,
or situations is a description of difficult children, which compose about 10% of the
population. Negative withdrawal responses are typical of this type of child, who requires a
more structured environment. Mood expressions are usually intense and primarily negative.
These children exhibit frequent periods of crying and often violent tantrums. Easy children
are even tempered, regular, and predictable in their habits. They are open and adaptable to
change. Approximately 40% of children fit this description. Slow-to-warm-up children
typically react negatively and with mild intensity to new stimuli and adapt slowly with
repeated contact. Approximately 10% of children fit this description. “Fast-to-warm-up” is
not one of the categories identified.
DIF: Cognitive Level: Apply
REF: p. 43
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
13. A 12-year-old child enjoys collecting stamps, playing soccer, and participating in Boy Scout
activities. The nurse recognizes that the child is displaying which developmental task?
Identity
Industry
Integrity
Intimacy
a.
b.
c.
d.
ANS: B
Industry is engaging in tasks that can be carried through to completion, learning to compete
and cooperate with others, and learning rules. Industry is the developmental task
characteristic of the school-age child. Identity is the developmental task of adolescence.
Integrity and intimacy are not developmental tasks of childhood.
DIF: Cognitive Level: Understand
REF: p. 38
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
14. A nurse is conducting parenting classes for parents of children ranging in ages 2 to 7 years.
The parents understand the term egocentrism when they indicate it means:
a. selfishness.
b. self-centeredness.
c. preferring to play alone.
d. unable to put self in another’s place.
ANS: D
According to Piaget, children ages 2 to 7 years are in the preoperational stage of
development. Children interpret objects and events not in terms of their general properties but
in terms of their relationships or their use to them. This egocentrism does not allow children
of this age to put themselves in another’s place. Selfishness, self-centeredness, and preferring
to play alone do not describe the concept of egocentricity.
DIF: Cognitive Level: Apply
REF: p. 45
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
15. The nurse is observing parents playing with their 10-month-old child. Which should the nurse
recognize as evidence that the child is developing object permanence?
a. Looks for the toy that parents hide under the blanket
b. Returns the blocks to the same spot on the table
c. Recognizes that a ball of clay is the same when flattened out
d. Bangs two cubes held in her hands
ANS: A
Object permanence is the realization that items that leave the visual field still exist. When the
infant searches for the toy under the blanket, it is an indication that object permanence has
developed. Returning the blocks to the same spot on the table is not an example of object
permanence. Recognizing that a ball of clay is the same when flattened out is an example of
conservation, which occurs during the concrete operations stage from 7 to 11 years. Banging
two cubes together is a simple repetitive activity characteristic of developing a sense of cause
and effect.
DIF: Cognitive Level: Apply
REF: p. 45
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A father tells the nurse that his child is “filling up the house with collections” like seashells,
bottle caps, baseball cards, and pennies. What should the nurse recognize the child is
developing?
a. Object permanence
b. Preoperational thinking
c. Concrete operational thinking
d. Ability to use abstract symbols
ANS: C
During concrete operations, children develop logical thought processes. They are able to
classify, sort, order, and otherwise organize facts about the world. This ability fosters the
child’s ability to create collections. Object permanence is the realization that items that leave
the visual field still exist. This is a task of infancy and does not contribute to collections.
Preoperational thinking is concrete and tangible. Children in this age group cannot reason
beyond the observable, and they lack the ability to make deductions or generalizations.
Collections are not typical for this developmental level. The ability to use abstract symbols is
a characteristic of formal operations, which develops during adolescence. These children can
develop and test hypotheses.
DIF: Cognitive Level: Understand
REF: p. 45
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. A visitor arrives at a daycare center during lunchtime. The preschool children think that every
time they have lunch a visitor will arrive. Which preoperational characteristic is being
displayed?
a. Egocentrism
b. Transductive reasoning
c. Intuitive reasoning
d. Conservation
ANS: B
Transductive reasoning is when two events occur together, they cause each other. The
expectation that every time lunch is served a visitor will arrive is descriptive of transductive
reasoning. Egocentrism is the inability to see things from any perspective than their own.
Intuitive reasoning (e.g., the stars have to go to bed just as they do) is predominantly
egocentric thought. Conservation (able to realize that physical factors such as volume,
weight, and number remain the same even though outward appearances are changed) does not
occur until school age.
DIF: Cognitive Level: Analyze
REF: p. 44
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Which behavior is most characteristic of the concrete operations stage of cognitive
development?
Progression from reflex activity to imitative behavior
Inability to put oneself in another’s place
Increasingly logical and coherent thought processes
Ability to think in abstract terms and draw logical conclusions
a.
b.
c.
d.
ANS: C
During the concrete operations stage of development, which occurs approximately between
ages 7 and 11 years, increasingly logical and coherent thought processes occur. This is
characterized by the child’s ability to classify, sort, order, and organize facts to use in problem
solving. The progression from reflex activity to imitative behavior is characteristic of the
sensorimotor stage of development. The inability to put oneself in another’s place is
characteristic of the preoperational stage of development. The ability to think in abstract
terms and draw logical conclusions is characteristic of the formal operations stage of
development.
DIF: Cognitive Level: Understand
REF: p. 45
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
19. According to Kohlberg, children develop moral reasoning as they mature. Which statement is
most characteristic of a preschooler’s stage of moral development?
Obeying the rules of correct behavior is important.
Showing respect for authority is important behavior.
Behavior that pleases others is considered good.
Actions are determined as good or bad in terms of their consequences.
a.
b.
c.
d.
ANS: D
Preschoolers are most likely to exhibit characteristics of Kohlberg’s preconventional level of
moral development. During this stage, they are culturally oriented to labels of good or bad,
right or wrong. Children integrate these concepts based on the physical or pleasurable
consequences of their actions. Obeying the rules of correct behavior, showing respect for
authority, and engaging in behavior that pleases others are characteristics of Kohlberg’s
conventional level of moral development.
DIF: Cognitive Level: Understand
REF: p. 46
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. A school nurse notes that school-age children generally obey the rules at school. The nurse
recognizes that the children are displaying which stage of moral development?
a. Preconventional
b. Conventional
c. Postconventional
d. Undifferentiated
ANS: B
Conventional stage of moral development is described as obeying the rules, doing one’s duty,
showing respect for authority, and maintaining the social order. This stage is characteristic of
school-age children’s behavior. The preconventional stage is characteristic of the toddler and
preschool age. At this stage, the child has no concept of the basic moral order that supports
being good or bad. The postconventional level is characteristic of an adolescent and occurs at
the formal stage of operation. Undifferentiated describes an infant’s understanding of moral
development.
DIF: Cognitive Level: Analyze
REF: p. 46
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
21. A nurse observes a toddler playing with sand and water. How should the nurse document this
type of play?
Skill
Dramatic
Social-affective
Sense-pleasure
a.
b.
c.
d.
ANS: D
The toddler playing with sand and water is engaging in sense-pleasure play. This is
characterized by nonsocial situations in which the child is stimulated by objects in the
environment. Infants engage in skill play when they persistently demonstrate and exercise
newly acquired abilities. Dramatic play is the predominant form of play in the preschool
period. Children pretend and fantasize. Social-affective play is one of the first types of play in
which infants engage. The infant responds to interactions with people.
DIF: Cognitive Level: Apply
REF: p. 47
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
22. In which type of play are children engaged in similar or identical activity, without
organization, division of labor, or mutual goal?
a. Solitary
b. Parallel
c. Associative
d. Cooperative
ANS: C
In associative play, no group goal is present. Each child acts according to his or her own
wishes. Although the children may be involved in similar activities, no organization, division
of labor, leadership assignment, or mutual goal exists. Solitary play describes children
playing alone with toys different from those used by other children in the same area. Parallel
play describes children playing independently but being among other children. Cooperative
play is organized. Children play in a group with other children who play in activities for a
common goal.
DIF: Cognitive Level: Understand
REF: p. 48
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
23. The nurse observes some children in the playroom. Which play situation exhibits the
characteristics of parallel play?
Kimberly and Amanda sharing clay to each make things
Brian playing with his truck next to Kristina playing with her truck
Adam playing a board game with Kyle, Steven, and Erich
Danielle playing with a music box on her mother’s lap
a.
b.
c.
d.
ANS: B
Playing with trucks next to each other but not together is an example of parallel play. Both
children are engaged in similar activities in proximity to each other; however, they are each
engaged in their own play. Sharing clay to make things is characteristic of associative play.
Friends playing a board game together is characteristic of cooperative play. A child playing
with something by herself on her mother’s lap is an example of solitary play.
DIF: Cognitive Level: Analyze
REF: p. 48
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
24. A nurse is planning play activities for school-age children. Which type of a play activity
should the nurse plan?
Solitary
Parallel
Associative
Cooperative
a.
b.
c.
d.
ANS: D
School-age children engage in cooperative play where it is organized and interactive. Playing
a game is a good example of cooperative play. Solitary play is appropriate for infants, parallel
play is an activity appropriate for toddlers, and associative play is an activity appropriate for
preschool-age children.
DIF: Cognitive Level: Apply
REF: p. 48
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
25. Which following function of play is a major component of play at all ages?
a. Creativity
b. Socialization
c. Intellectual development
d. Sensorimotor activity
ANS: D
Sensorimotor activity is a major component of play at all ages. Active play is essential for
muscle development and allows the release of surplus energy. Through sensorimotor play,
children explore their physical world by using tactile, auditory, visual, and kinesthetic
stimulation. Creativity, socialization, and intellectual development are each functions of play
that are major components at different ages.
DIF: Cognitive Level: Understand
REF: p. 49
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Developmental Stages and
Transitions
26. Parents are asking the clinic nurse about an appropriate toy for their toddler. Which response
by the nurse is appropriate?
a. “Your child would enjoy playing a board game.”
b. “A toy your child can push or pull would help develop muscles.”
c. “An action figure toy would be a good choice.”
d. “A 25-piece puzzle would help your child develop recognition of shapes.”
ANS: B
Toys should be appropriate for the child’s age. A toddler would benefit from a toy he or she
could push or pull. The child is too young for a board game, action figure, or 25-piece puzzle.
DIF: Cognitive Level: Apply
REF: p. 50
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
27. Which is probably the single most important influence on growth at all stages of
development?
a. Nutrition
b. Heredity
c. Culture
d. Environment
ANS: A
Nutrition is the single most important influence on growth. Dietary factors regulate growth at
all stages of development, and their effects are exerted in numerous and complex ways.
Adequate nutrition is closely related to good health throughout life. Heredity, culture, and
environment contribute to the child’s growth and development. However, good nutrition is
essential throughout the life span for optimal health.
DIF: Cognitive Level: Understand
REF: p. 43
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
28. A nurse is counseling an adolescent, in her second month of pregnancy, about the risk of
teratogens. The adolescent has understood the teaching if she makes which statement?
a.
b.
c.
d.
“I will be able to continue taking isotretinoin (Accutane) for my acne.”
“I can continue to clean my cat’s litter box.”
“I should avoid any alcoholic beverages.”
“I will ask my physician to adjust my phenytoin (Dilantin) dosage.”
ANS: C
Teratogens are agents that cause birth defects when present in the prenatal period. Avoidance
of alcoholic beverages is recommended to prevent fetal alcohol syndrome. Isotretinoin
(Accutane) and phenytoin (Dilantin) have been shown to have teratogenic effects and should
not be taken during pregnancy. Cytomegalovirus, an infectious agent and a teratogen, can be
transmitted through cat feces, and cleaning the litter box during pregnancy should be avoided.
DIF: Cognitive Level: Analyze
REF: p. 52
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
29. What should the nurse consider when discussing language development with parents of
toddlers?
Sentences by toddlers include adverbs and adjectives.
The toddler expresses himself or herself with verbs or combination words.
The toddler uses simple sentences.
Pronouns are used frequently by the toddler.
a.
b.
c.
d.
ANS: B
The first parts of speech used are nouns, sometimes verbs (e.g., “go”), and combination
words (e.g., “bye-bye”). Responses are usually structurally incomplete during the toddler
period. The preschool child begins to use adjectives and adverbs to qualify nouns followed by
adverbs to qualify nouns and verbs. Pronouns are not added until the later preschool years.
By the time children enter school, they are able to use simple, structurally complete sentences
that average five to seven words.
DIF: Cognitive Level: Apply
REF: p. 46
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
30. A nurse is observing children at play. Which figure depicts associative play?
a.
b.
c.
d.
ANS: C
The children depicted in the figure at the carnival ride are demonstrating associative play.
They are engaged in similar or identical activities. The child depicted playing alone is
demonstrating solitary play. The children playing on the beach depict parallel play. They are
playing side by side but are participating in different activities. The children depicted playing
a board game are engaging in cooperative play.
DIF: Cognitive Level: Analyze
REF: p. 48
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
31. Which syndrome involves a common sex chromosome defect?
a. Down
b. Turner
c. Marfan
d. Hemophilia
ANS: B
Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is
caused by trisomy 21, three copies rather than two copies of chromosome 21. Marfan
syndrome is a connective tissue disorder inherited in an autosomal dominant pattern.
Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.
DIF: Cognitive Level: Understand
REF: p. 52
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. Turner syndrome is suspected in an adolescent girl with short stature. What is the cause of
this syndrome?
a. Absence of one of the X chromosomes
b. Presence of an incomplete Y chromosome
c. Precocious puberty in an otherwise healthy child
d. Excess production of both androgens and estrogens
ANS: A
Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have
this disorder have one X chromosome missing from all cells. No Y chromosome is present in
individuals with Turner syndrome. This young woman has 45 rather than 46 chromosomes.
DIF: Cognitive Level: Understand
REF: p. 52
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. Play serves many purposes. In teaching parents about appropriate activities, the nurse should
inform them that play serves which of the following function? (Select all that apply.)
a. Intellectual development
b. Physical development
c. Socialization
d. Creativity
e. Temperament development
ANS: A, C, D
A common statement is that play is the work of childhood. Intellectual development is
enhanced through the manipulation and exploration of objects. Socialization is encouraged by
interpersonal activities and learning of social roles. In addition, creativity is developed
through the experimentation characteristic of imaginative play. Physical development
depends on many factors; play is not one of them. Temperament refers to behavioral
tendencies that are observable from the time of birth. The actual behaviors, but not the child’s
temperament attributes, may be modified through play.
DIF: Cognitive Level: Understand
REF: p. 49
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. What factors indicate parents should seek genetic counseling for their child? (Select all that
apply.)
a. Abnormal newborn screen
b. Family history of a hereditary disease
c. History of hypertension in the family
d. Severe colic as an infant
e. Metabolic disorder
ANS: A, B, E
Factors that are indicative parents should seek genetic counseling for their child include an
abnormal newborn screen, family history of a hereditary disease, and a metabolic disorder. A
history of hypertension or severe colic as an infant is not an indicator of a genetic disease.
DIF: Cognitive Level: Understand
REF: p. 53
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is preparing to administer a Denver II. Which is a correct statement about the Denver
II? (Select all that apply.)
All items intersected by the age line should be administered.
There is no correction for a child born preterm.
The tool is an intelligence test.
Toddlers and preschoolers should be prepared by presenting the test as a game.
Presentation of the toys from the kit should be done one at a time.
a.
b.
c.
d.
e.
ANS: A, D, E
To identify “cautions,” all items intersected by the age line are administered. Toddlers and
preschoolers should be tested by presenting the Denver II as a game. Because children are
easily distracted, perform each item quickly and present only one toy from the kit at a time.
Before beginning the screening, ask whether the child was born preterm and correctly
calculate the adjusted age. Up to 24 months of age, allowances are made for preterm infants
by subtracting the number of weeks of missed gestation from their present age and testing
them at the adjusted age. Explain to the parents and child, if appropriate, that the screenings
are not intelligence tests but rather are a method of showing what the child can do at a
particular age.
DIF: Cognitive Level: Apply
REF: p. 50
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
COMPLETION
1. The nurse is recording a normal interpretation of a Denver II assessment. The nurse
understands that the maximum number of cautions determined for a normal interpretation is
_____. (Record your answer in a whole number.)
ANS:
1
Interpretation of normal for a Denver II is no delays and a maximum of one caution.
DIF: Cognitive Level: Apply
REF: p. 50
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the sequence of cephalocaudal development that the nurse expects to find in
the infant. Begin with the first development expected, sequencing to the final. Provide
answers using lowercase letters separated by commas (e.g., a, b, c, d).
a. Crawl
b. Sit unsupported
c. Lift head when prone
d. Gain complete head control
e. Walk
ANS:
c, d, b, a, e
Cephalocaudal development is head-to-tail. Infants achieve structural control of the head
before they have control of their trunks and extremities, they lift their head while prone,
obtain complete head control, sit unsupported, crawl, and walk sequentially.
DIF: Cognitive Level: Apply
REF: p. 38
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 04: Communication and Physical Assessment of the Child and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should
the nurse do first?
a.
b.
c.
d.
Introduce self.
Make family comfortable.
Explain purpose of interview.
Give assurance of privacy.
ANS: A
The first thing that nurses should do is to introduce themselves to the patient and family. Parents
and other adults should be addressed with appropriate titles unless they specify a preferred name.
During the initial part of the interview, the nurse should include general conversation to help
make the family feel at ease. Clarification of the purpose of the interview and the nurse’s role is
the next thing that should be done. The interview should take place in an environment as free of
distraction as possible. In addition, the nurse should clarify which information will be shared
with other members of the health care team and any limits to the confidentiality.
DIF: Cognitive Level: Apply
REF: p. 57
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
2. Which is most likely to encourage parents to talk about their feelings related to their child’s ill-
ness?
a.
b.
c.
d.
Be sympathetic.
Use direct questions.
Use open-ended questions.
Avoid periods of silence.
ANS: C
Closed-ended questions should be avoided when attempting to elicit parents’ feelings. Open-
ended questions require the parent to respond with more than a brief answer. Sympathy is having
feelings or emotions in common with another person rather than understanding those feelings
(empathy). Sympathy is not therapeutic in helping the relationship. Direct questions may obtain
limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the
emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for
responses to questions.
DIF: Cognitive Level: Apply
REF: p. 58
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
3. Which communication technique should the nurse avoid when interviewing children and their
families?
a.
b.
c.
d.
Using silence
Using clichés
Directing the focus
Defining the problem
ANS: B
Using stereotyped comments or clichés can block effective communication, and this technique
should be avoided. After use of such trite phrases, parents will often not respond. Silence can be
an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings
and search for responses to questions. To be effective, the nurse must be able to direct the focus
of the interview while allowing maximal freedom of expression. By using open-ended questions,
along with guiding questions, the nurse can obtain the necessary information and maintain the relationship with the family. The nurse and parent must collaborate and define the problem that
will be the focus of the nursing intervention.
DIF: Cognitive Level: Understand
REF: p. 59
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
4. What is the single most important factor to consider when communicating with children?
a.
The child’s physical condition
b.
Presence or absence of the child’s parent
c.
The child’s developmental level
d.
The child’s nonverbal behaviors
ANS: C
The nurse must be aware of the child’s developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child’s physical condition is a consideration, developmental level is
much more important. The parents’ presence is important when communicating with young children but may be detrimental when speaking with adolescents. Nonverbal behaviors will vary in
importance, based on the child’s developmental level.
DIF: Cognitive Level: Understand
REF: p. 60
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
5. Which approach would be best to use to ensure a positive response from a toddler?
a.
Assume an eye-level position and talk quietly.
b.
Call the toddler’s name while picking him or
c.
d.
her up.
Call the toddler’s name and say, “I’m your
nurse.”
Stand by the toddler, addressing him or her by
name.
ANS: A
It is important that the nurse assume a position at the child’s level when communicating with the
child. By speaking quietly and focusing on the child, the nurse should be able to obtain a positive
response. The nurse should engage the child and inform the toddler what is going to occur. If the
nurse picks up the child without explanation, the child is most likely going to become upset. The
toddler may not understand the meaning of the phrase, “I’m your nurse.” If a positive response is
desired, the nurse should assume the child’s level when speaking if possible.
DIF: Cognitive Level: Apply
REF: p. 60
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
6. What is an important consideration for the nurse who is communicating with a very young child?
a.
Speak loudly, clearly, and directly.
b.
Use transition objects, such as a doll.
c.
Disguise own feelings, attitudes, and anxiety.
d.
Initiate contact with child when parent is not
present.
ANS: B
Using a transition object allows the young child an opportunity to evaluate an unfamiliar person
(the nurse). This will facilitate communication with a child this age. Speaking in this manner will
tend to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception will lead to a lack of trust. Whenever possible, the parent should be present
for interactions with young children.
DIF: Cognitive Level: Understand
REF: p. 61
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
7. A nurse is preparing to assess a 3-year-old child. What communication technique should the
nurse use for this child?
a.
b.
c.
d.
ANS: A
Focus communication on child.
Explain experiences of others to child.
Use easy analogies when possible.
Assure child that communication is private.
Because children of this age are able to see things only in terms of themselves, the best approach
is to focus communication directly on them. Children should be provided with information about
what they can do and how they will feel. With children who are egocentric, experiences of others, analogies, and assurances that the communication is private will not be effective because the
child is not capable of understanding.
DIF: Cognitive Level: Apply
REF: p. 61
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
8. A nurse is assigned to four children of different ages. In which age group should the nurse under-
stand that body integrity is a concern?
a.
b.
c.
d.
Toddler
Preschooler
School-age child
Adolescent
ANS: C
School-age children have a heightened concern about body integrity. They place importance and
value on their bodies and are oversensitive to anything that constitutes a threat or suggestion of
injury. Body integrity is not as important a concern to toddlers, preschoolers, or adolescents.
DIF: Cognitive Level: Understand
REF: p. 61
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most ap-
propriate nursing action?
a.
b.
c.
d.
Ask her why she wants to know.
Determine why she is so anxious.
Explain in simple terms how it works.
Tell her she will see how it works as it is
used.
ANS: C
School-age children require explanations and reasons for everything. They are interested in the
functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. A nurse should respond positively
for requests for information about procedures and health information. By not responding, the
nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification of what will be occurring. The nurse must explain how the blood pressure
cuff works so that the child can then observe during the procedure.
DIF: Cognitive Level: Apply
REF: p. 61
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. When the nurse interviews an adolescent, which is especially important?
a.
Focus the discussion on the peer group.
b.
c.
d.
Allow an opportunity to express feelings.
Emphasize that confidentiality will always be
maintained.
Use the same type of language as the adoles
cent.
ANS: B
Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age group, the focus of the interview should be on the
adolescent. The nurse should clarify which information will be shared with other members of the
health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent
may use, the nurse should clarify terms frequently.
DIF: Cognitive Level: Understand
REF: p. 62
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
11. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What tech-
nique might be most helpful?
a.
b.
c.
d.
Suggest that the child keep a diary.
Suggest that the parent read fairy tales to the
child.
Ask the parent if the child is always uncommunicative.
Ask the child to draw a picture.
ANS: D
Drawing is one of the most valuable forms of communication. Children’s drawings tell a great
deal about them because they are projections of the child’s inner self. It would be difficult for a
6-year-old child who is most likely learning to read to keep a diary. Parents reading fairy tales to
the child is a passive activity involving the parent and child. It would not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with
strangers.
DIF: Cognitive Level: Apply
REF: p. 64
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
12. The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate
during a dressing change. The nurse decides to do a simple magic trick using gauze. How should
this action be interpreted?
a.
Inappropriate, because of child’s age
b.
A way to establish rapport
c.
Too distracting, when cooperation is important
d.
Acceptable, if there is adequate time
ANS: B
A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent
method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the
natural curiosity of young children. The nurse should establish rapport with the child. Failure to
do so may cause the procedure to take longer and be more traumatic.
DIF: Cognitive Level: Analyze
REF: p. 64
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
13. The nurse must assess a 10-month-old infant. The infant is sitting on the father’s lap and appears
to be afraid of the nurse and of what might happen next. Which initial action by the nurse would
be most appropriate?
a.
Initiate a game of peek-a-boo.
b.
Ask father to place the infant on the examina
tion table.
c.
Undress the infant while he is still sitting on
his father’s lap.
d.
Talk softly to the infant while taking him
from his father.
ANS: A
Peek-a-boo is an excellent means of initiating communication with infants while maintaining a
safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done on the father’s lap. The nurse should
have the father undress the child as needed for the examination.
DIF: Cognitive Level: Apply
REF: p. 62
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
14. The nurse is taking a health history on an adolescent. Which best describes how the chief com-
plaint should be determined?
a.
b.
c.
d.
Ask for detailed listing of symptoms.
Ask adolescent, “Why did you come here to
day?”
Use what adolescent says to determine, in
correct medical terminology, what the problem is.
Interview parent away from adolescent to de
termine chief complaint.
ANS: B
The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief
complaint. A detailed listing of symptoms will make it difficult to determine the chief complaint.
The adolescent should be prompted to tell which symptom caused him to seek help at this time.
The chief complaint is usually written in the words that the parent or adolescent uses to describe
the reason for seeking help. The parent and adolescent may be interviewed separately, but the
nurse should determine the reason the adolescent is seeking attention at this time.
DIF: Cognitive Level: Apply
REF: p. 62
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. Where in the health history should the nurse describe all details related to the chief complaint?
a.
Past history
b.
Chief complaint
c.
Present illness
d.
Review of systems
ANS: C
The history of the present illness is a narrative of the chief complaint from its earliest onset
through its progression to the present. The focus of the present illness is on all factors relevant to
the main problem, even if they have disappeared or changed during the onset, interval, and
present. Past history refers to information that relates to previous aspects of the child’s health, not
to the current problem. The chief complaint is the specific reason for the child’s visit to the
clinic, office, or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.
DIF: Cognitive Level: Understand
REF: p. 64
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
16. The nurse is interviewing the mother of an infant. She reports, “I had a difficult delivery, and my
baby was born preterm.” This information should be recorded under which of the following
headings?
a.
Past history
b.
Present illness
c.
Chief complaint
d.
Review of systems
ANS: A
The past history refers to information that relates to previous aspects of the child’s health, not to
the current problem. The mother’s difficult delivery and prematurity are important parts of the
past history of an infant. The history of the present illness is a narrative of the chief complaint
from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness.
The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. It
would not include the birth information. The review of systems is a specific review of each body
system. It does not include the preterm birth. Sequelae such as pulmonary dysfunction would be
included.
DIF: Cognitive Level: Understand
REF: p. 65
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Which is most important to document about immunizations in the child’s health history?
a.
b.
c.
d.
Dosage of immunizations received
Occurrence of any reaction after an immunization
The exact date the immunizations were received
Practitioner who administered the immuniza
tions
ANS: B
The occurrence of any reaction after an immunization was given is the most important to document in a history because of possible future reactions, especially allergic reactions. Exact dosage
of the immunization received may not be recorded on the immunization record. Exact dates are
important to obtain but not as important as a history of reaction to an immunization. The practitioner who administered the immunization does not need to be recorded in the health history. A
potentially severe physiologic response is the most threatening and most important information
to document for safety reasons.
DIF: Cognitive Level: Analyze
REF: p. 65
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
18. When interviewing the mother of a 3-year-old child, the nurse asks about developmental mile-
stones such as the age of walking without assistance. How should this question be considered?
a.
Unnecessary information because child is age
3 years
b.
An important part of the family history
c.
An important part of the child’s past history
d.
An important part of the child’s review of
systems
ANS: C
Information about the attainment of developmental milestones is important to obtain. It provides
data about the child’s growth and development that should be included in the past history. Developmental milestones provide important information about the child’s physical, social, and neurologic health and should be included in the history for a 3-year-old child. If pertinent, attainment
of milestones by siblings would be included in the family history. The review of systems does
not include the developmental milestones.
DIF: Cognitive Level: Understand
REF: p. 65
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
19. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine
whether she is sexually active?
a.
b.
c.
Ask her, “Are you sexually active?”
Ask her, “Are you having sex with anyone?”
Ask her, “Are you having sex with a
boyfriend?”
d.
Ask both the girl and her parent whether she
is sexually active.
ANS: B
Asking the adolescent girl whether she is having sex with anyone is a direct question that is well
understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific
terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is
preferable to use gender-neutral terms. Questioning about sexual activity should occur when the
adolescent is alone.
DIF: Cognitive Level: Apply
REF: p. 65
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
20. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet con-
sists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?
a.
Indicates they live in poverty
b.
Is lacking in protein
c.
May provide sufficient amino acids
d.
Should be enriched with meat and milk
ANS: C
The diet that contains vegetable, legumes, and starches may provide sufficient essential amino
acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that
contain this combination of foods. It is not indicative of poverty. Combinations of foods contain
the essential amino acids necessary for growth. A dietary assessment should be done, but many
vegetarian diets are sufficient for growth.
DIF: Cognitive Level: Understand
REF: p. 66
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
21. Which following parameters correlates best with measurements of the body’s total protein
stores?
a.
b.
c.
d.
Height
Weight
Skinfold thickness
Upper arm circumference
ANS: D
Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves
as the body’s major protein reserve and is considered an index of the body’s protein stores.
Height is reflective of past nutritional status. Weight is indicative of current nutritional status.
Skinfold thickness is a measurement of the body’s fat content.
DIF: Cognitive Level: Understand
REF: p. 72
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
22. A nurse is preparing to perform a physical assessment on a toddler. Which approach should the
nurse use for this child?
a.
b.
c.
d.
Always proceed in a head-to-toe direction.
Perform traumatic procedures first.
Use minimal physical contact initially.
Demonstrate use of equipment.
ANS: C
Parents can remove clothing, and the child can remain on the parent’s lap. The nurse should use
minimal physical contact initially to gain the child’s cooperation. The head-to-toe assessment can
be done in older children but usually must be adapted in younger children. Traumatic procedures
should always be performed last. These will most likely upset the child and inhibit cooperation.
The nurse should introduce the equipment slowly. The child can inspect the equipment, but
demonstrations are usually too complex for toddlers.
DIF: Cognitive Level: Apply
REF: p. 77
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
23. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives
her the option of her mother either staying in the room or leaving. How should this action be interpreted?
a.
Appropriate because of child’s age
b.
Appropriate because mother would be uncomfortable making decisions for child
c.
Inappropriate because of child’s age
d.
Inappropriate because child is same sex as
mother
ANS: A
The older school-age child should be given the option of having the parent present or not. During
the examination, the nurse should respect the child’s need for privacy. Although the question was
appropriate for the child’s age, the mother is responsible for making decisions for the child. It is
appropriate because of the child’s age. During the examination, the nurse must respect the child’s
privacy. The child should help determine who is present during the examination.
DIF: Cognitive Level: Apply
REF: p. 77
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
24. A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse
accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being
overweight?
a.
10th percentile
b.
9th percentile
c.
85th percentile
d.
95th percentile
ANS: C
Children who have BMI-for-age greater than or equal to the 85th percentile and less than the
95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are
within normal limits. Children who are greater than or equal to the 95th percentile are considered
overweight.
DIF: Cognitive Level: Apply
REF: p. 79
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
25. The nurse is using the Centers for Disease Control and Prevention (CDC) growth chart for an
African-American child. Which statement should the nurse consider?
a.
This growth chart should not be used.
b.
Growth patterns of African-American children are the same as for all other ethnic
groups.
c.
A correction factor is necessary when the
CDC growth chart is used for non-Caucasian
ethnic groups.
d.
The CDC charts are accurate for US AfricanAmerican children.
ANS: D
The CDC growth charts can serve as reference guides for all racial or ethnic groups. US AfricanAmerican children were included in the sample population. The growth chart can be used with
the perspective that different groups of children have varying normal distributions on the growth
curves. No correction factor exists.
DIF: Cognitive Level: Understand
REF: p. 77
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
26. Which tool measures body fat most accurately?
a.
Stadiometer
b.
Calipers
c.
Cloth tape measure
d.
Paper or metal tape measure
ANS: B
Calipers are used to measure skinfold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can
stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.
DIF: Cognitive Level: Understand
REF: p. 80
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
27. The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school-age
child. What is the purpose of doing this?
a.
b.
c.
d.
To measure body fat
To measure muscle mass
To determine arm circumference
To determine accuracy of weight measurement
ANS: A
Measurement of skinfold thickness is an indicator of body fat. Arm circumference is an indirect
measure of muscle mass. The accuracy of weight measurement should be verified with a properly balanced scale. Body fat is just one indicator of weight.
DIF: Cognitive Level: Remember
REF: p. 80
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
28. A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse
interprets this as a normal finding because the head and chest circumference become equal at
which age?
a.
1 month
b.
6 to 9 months
c.
1 to 2 years
d.
to 3 years
ANS: C
Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they
become approximately equal. Head circumference is larger than chest circumference before age
1. Chest circumference is larger than head circumference at to 3 years.
DIF: Cognitive Level: Remember
REF: p. 80
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
29. Which would be best for the nurse to use when determining the temperature of a preterm infant
under a radiant heater?
a.
b.
c.
d.
Axillary sensor
Tympanic membrane sensor
Rectal mercury glass thermometer
Rectal electronic thermometer
ANS: A
The axillary sensor measures the infrared heat energy radiating from the axilla. It can be used on
wet skin, in incubators, or under radiant warmers. Ear thermometry does not show sufficient correlation with established methods of measurement. It should not be used when body temperature
must be assessed with precision. Mercury thermometers should never be used. The release of
mercury, should the thermometer be broken, can cause harmful vapors. Rectal temperatures
should be avoided unless no other suitable way exists for the temperature to be measured.
DIF: Cognitive Level: Apply
REF: p. 85
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
30. What is the earliest age at which a satisfactory radial pulse can be taken in children?
a.
1 year
b.
2 years
c.
3 years
d.
6 years
ANS: B
Satisfactory radial pulses can be used in children older than 2 years. In infants and young children, the apical pulse is more reliable. The apical pulse can be used for assessment at these ages.
DIF: Cognitive Level: Remember
REF: p. 103
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
31. Pulses can be graded according to certain criteria. Which is a description of a normal pulse?
a.
0
b.
+1
c.
+2
d.
+3
ANS: D
A normal pulse is described as +3. A pulse that is easy to palpate and not easily obliterated with
pressure is considered normal. A pulse graded 0 is not palpable. A pulse graded +1 is difficult to
palpate, thready, weak, and easily obliterated with pressure. A pulse graded +2 is difficult to palpate and may be easily obliterated with pressure.
DIF: Cognitive Level: Remember
REF: p. 85
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
32. Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
a.
Face
b.
Buttocks
c.
Oral mucosa
d.
Palms and soles
ANS: C
Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in
the mouth or conjunctiva.
DIF: Cognitive Level: Remember
REF: p. 89
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
33. The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How
should the nurse document these findings?
a.
Normal
b.
c.
d.
Erythema
Jaundice
Ecchymosis
ANS: C
Jaundice is defined as the yellow staining of the skin, usually by bile pigments. Yellow staining is
not a normal appearance of the skin. Erythema is redness that results from increased blood flow
to the area. Ecchymosis is large, diffuse areas, usually black and blue, caused by hemorrhage of
blood into the skin.
DIF: Cognitive Level: Understand
REF: p. 89
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
34. When palpating the child’s cervical lymph nodes, the nurse notes that they are tender, enlarged,
and warm. What is the best explanation for this?
Some form of cancer
Local scalp infection common in children
Infection or inflammation distal to the site
Infection or inflammation close to the site
a.
b.
c.
d.
ANS: D
Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes are not usually indicative of
cancer. A scalp infection would usually not cause inflamed lymph nodes. The lymph nodes close
to the site of inflammation or infection would be inflamed.
DIF: Cognitive Level: Analyze
REF: p. 89
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
35. During a routine health assessment, the nurse notes that an 8-month-old infant has significant
head lag. Which is the nurse’s most appropriate action?
a.
Teach parents appropriate exercises.
b.
Recheck head control at next visit.
c.
Refer child for further evaluation.
d.
Refer child for further evaluation if anterior
fontanel is still open.
ANS: C
Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.
DIF: Cognitive Level: Apply
REF: p. 89
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
36. The nurse has just started assessing a young child who is febrile and appears very ill. There is hy-
perextension of the child’s head (opisthotonos) with pain on flexion. Which is the most appropriate action?
a.
Refer for immediate medical evaluation.
b.
Continue assessment to determine cause of
neck pain.
c.
Ask parent when neck was injured.
d.
Record “head lag” on assessment record, and
continue assessment of child.
ANS: A
Hyperextension of the child’s head with pain on flexion is indicative of meningeal irritation and
needs immediate evaluation; it is not descriptive of head lag. The pain is indicative of meningeal
irritation. No indication of injury is present.
DIF: Cognitive Level: Apply
REF: p. 90
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
37. At what age should the nurse expect the anterior fontanel to close?
a.
2 months
b.
2 to 4 months
c.
6 to 8 months
d.
12 to 18 months
ANS: D
The anterior fontanel normally closes between ages 12 and 18 months. Two to 8 months is too
early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it
closes between ages 2 and 8 months, the child should be referred for further evaluation.
DIF: Cognitive Level: Remember
REF: p. 90
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
38. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red
reflex in both eyes. How should the nurse interpret this finding?
a.
Normal finding
b.
Abnormal finding, so child needs referral to
ophthalmologist
c.
Sign of possible visual defect, so child needs
vision screening
d.
Sign of small hemorrhages, which will usually resolve spontaneously
ANS: A
A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of
the cornea, aqueous chamber, lens, and vitreous chamber.
DIF: Cognitive Level: Understand
REF: p. 91
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
39. Parents of a newborn are concerned because the infant’s eyes often “look crossed” when the in-
fant is looking at an object. The nurse’s response is that this is normal based on the knowledge
that binocularity is normally present by what age?
a.
1 month
b.
3 to 4 months
c.
6 to 8 months
d.
12 months
ANS: B
Binocularity is usually achieved by ages 3 to 4 months. 1 month is too young. If binocularity is
not achieved by ages 6 to 12 months, the child must be observed for strabismus.
DIF: Cognitive Level: Understand
REF: p. 91
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
40. A nurse is preparing to test a school-age child’s vision. Which eye chart should the nurse use?
a.
Denver Eye Screening Test
b.
Allen picture card test
c.
Ishihara vision test
d.
Snellen letter chart
ANS: D
The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity for school-age children. Single cards (Denver—letter E; Allen
—pictures) are used for children ages 2 years and older who are unable to use the Snellen letter
chart. The Ishihara vision test is used for color vision.
DIF: Cognitive Level: Apply
REF: p. 92
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
41. Which is the most appropriate vision acuity test for a child who is in preschool?
a.
Cover test
b.
Ishihara test
c.
HOTV chart
d.
Snellen letter chart
ANS: C
The HOTV test consists of a wall chart of these letters. The child is asked to point to a corresponding card when the examiner selects one of the letters on the chart. The cover test determines ocular alignment. The Ishihara test is used for the detection of color blindness. The
Snellen letter chart is usually used for older children.
DIF: Cognitive Level: Understand
REF: p. 93
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
42. The nurse is testing an infant’s visual acuity. By what age should the infant be able to fix on and
follow a target?
a.
b.
c.
d.
1 month
1 to 2 months
3 to 4 months
6 months
ANS: C
Visual fixation and following a target should be present by ages 3 to 4 months. One to 2 months
is too young for this developmental milestone. If the infant is not able to fix and follow by 6
months, further ophthalmologic evaluation is needed.
DIF: Cognitive Level: Understand
REF: p. 93
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Health Promotion and Maintenance
43. Where is the appropriate placement of a tongue blade for assessment of the mouth and throat?
a.
Center back area of tongue
b.
Side of the tongue
c.
Against the soft palate
d.
On the lower jaw
ANS: B
Side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement in the center back area of the tongue will elicit the gag reflex. Against the soft palate and on
the lower jaw are not appropriate places for the tongue blade.
DIF: Cognitive Level: Understand
REF: p. 98
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
44. What is an appropriate screening test for hearing that can be administered by the nurse to a 5-
year-old child?
a.
b.
c.
d.
The Rinne test
The Weber test
Conventional audiometry
Eliciting the startle reflex
ANS: C
Conventional audiometry is a behavioral test that measures auditory thresholds in response to
speech and frequency-specific stimuli presented through earphones. The Rinne and Weber tests
measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.
DIF: Cognitive Level: Understand
REF: p. 97
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
45. What type of breath sound is normally heard over the entire surface of the lungs except for the
upper intrascapular area and the area beneath the manubrium?
a.
b.
c.
d.
Vesicular
Bronchial
Adventitious
Bronchovesicular
ANS: A
Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard
only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually
heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions
where trachea and bronchi bifurcate.
DIF: Cognitive Level: Remember
REF: p. 101
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
46. A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the
nurse expect to assess?
a.
b.
c.
d.
Rubs
Rattles
Wheezes
Crackles
ANS: C
Asthma causes bronchoconstriction and narrowed passageways. Wheezes are produced as air
passes through narrowed passageways. Rubs are the sound created by the friction of one surface
rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles
is the term formerly used for crackles. Crackles are the sounds made when air passes through
fluid or moisture.
DIF: Cognitive Level: Analyze
REF: p. 102
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
47. While caring for a critically ill child, the nurse observes that respirations are gradually increasing
in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?
a.
Dyspnea
b.
Tachypnea
c.
Cheyne-Stokes respirations
d.
Seesaw (paradoxic) respirations
ANS: C
Cheyne-Stokes respirations are a pattern of respirations that gradually increase in rate and depth,
with periods of apnea. Dyspnea is defined as distress during breathing. Tachypnea is an increased
respiratory rate. In seesaw respirations, the chest falls on inspiration and rises on expiration.
DIF: Cognitive Level: Understand
REF: p. 102
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
48. How does the nurse assess a child’s capillary refill time?
a.
Inspecting the chest
b.
Auscultating the heart
c.
Palpating the apical pulse
d.
Palpating the skin to produce a slight blanch
ing
ANS: D
Capillary refill time is assessed by pressing lightly on the skin to produce blanching, and then
noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary refill
time.
DIF: Cognitive Level: Understand
REF: p. 102
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
49. A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does
the nurse expect to assess?
a.
b.
c.
d.
S3
S4
Murmur
Physiologic splitting
ANS: C
Murmurs are the sounds that are produced in the heart chambers or major arteries from the backand-forth flow of blood. These are the sounds expected to be heard in a child with a ventricular
septal defect because of the abnormal opening between the ventricles. S3 is a normal heart sound
sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on
inspiration. It is a significant normal finding.
DIF: Cognitive Level: Analyze
REF: p. 103
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
50. The nurse has determined the rate of both the child’s radial pulse and heart. What is the normal
finding when comparing the two rates?
a.
b.
c.
d.
Are the same
Differ, with heart rate faster
Differ, with radial pulse faster
Differ, depending on quality and intensity
ANS: A
Pulses are the fluid wave through the blood vessel as a result of each heartbeat. Therefore, they
should be the same.
DIF: Cognitive Level: Understand
REF: p. 103
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
51. A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse
pull the pinna for this age of child?
a.
b.
c.
d.
Up and back
Down and back
Straight back
Straight up
ANS: A
With older children, usually those older than 3 years of age, the canal curves downward and forward. Therefore, pull the pinna up and back during otoscopic examinations. In infants, the canal
curves upward. Therefore, pull the pinna down and back to straighten the canal. Pulling the pinna
straight back or straight up will not open the inner ear canal.
DIF: Cognitive Level: Understand
REF: p. 95
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
52. The nurse has a 2-year-old boy sit in “tailor” position during palpation for the testes. What is the
rationale for this position?
a.
b.
c.
d.
It prevents cremasteric reflex.
Undescended testes can be palpated.
This tests the child for an inguinal hernia.
The child does not yet have a need for privacy.
ANS: A
The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its
contraction, which pulls the testes into the pelvic cavity. Undescended testes cannot be predictably palpated. Inguinal hernias are not detected by this method. This position is used for inhibiting the cremasteric reflex. Privacy should always be provided for children.
DIF: Cognitive Level: Understand
REF: p. 107
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
53. During examination of a toddler’s extremities, the nurse notes that the child is bowlegged. What
should the nurse recognize regarding this finding?
a.
Abnormal and requires further investigation
b.
Abnormal unless it occurs in conjunction with
knock-knee
c.
Normal if the condition is unilateral or asym
metric
d.
Normal because the lower back and leg mus
cles are not yet well developed
ANS: D
Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk. It usually persists until all their lower back and leg muscles are well developed. Further evaluation is
needed if it persists beyond ages 2 to 3 years, especially in African-American children.
DIF: Cognitive Level: Understand
REF: p. 108
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Health Promotion and Maintenance
54. At about what age does the Babinski sign disappear?
a.
4 months
b.
6 months
c.
1 year
d.
2 years
ANS: C
The presence of the Babinski reflex after about age 1 year, when walking begins, is abnormal.
Four to 6 months is too young for the disappearance of the Babinski reflex. Persistence of the
Babinski reflex requires further evaluation.
DIF: Cognitive Level: Understand
REF: p. 109
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
55. A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the
“finger-to-nose” test. What is the nurse testing for?
Deep tendon reflexes
Cerebellar function
Sensory discrimination
Ability to follow directions
a.
b.
c.
d.
ANS: B
The finger-to-nose test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Each sense is tested separately. Although
this test enables the nurse to evaluate the child’s ability to follow directions, it is used primarily
for cerebellar function.
DIF: Cognitive Level: Apply
REF: p. 109
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
56. Which figure depicts a nurse performing a test for the triceps reflex?
a.
b.
c.
d.
ANS: A
To test the triceps reflex, the child is placed supine, with the forearm resting over the chest and
the triceps tendon is struck with the reflex hammer. The other figures depict tests for biceps re-
flex (slightly above the antecubital space) patellar (knee), and Achilles (behind the foot).
DIF: Cognitive Level: Analyze
REF: p. 110
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-
month checkup. What criteria should the nurse use in determining the appropriate-size blood
pressure cuff? (Select all that apply.)
a.
The cuff is labeled “toddler.”
b.
The cuff bladder width is approximately 40%
of the circumference of the upper arm.
c.
The cuff bladder length covers 80% to 100%
of the circumference of the upper arm.
d.
The cuff bladder covers 50% to 66% of the
length of the upper arm.
ANS: B, C
Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. This size cuff will most accurately reflect measured radial artery pressure. The name of the
cuff is a representative size that may not be suitable for any individual child. Choosing a cuff by
limb circumference more accurately reflects arterial pressure than choosing a cuff by length.
DIF: Cognitive Level: Understand
REF: p. 86
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which of the following data would be included in a health history? (Select all that apply.)
a.
Review of systems
b.
Physical assessment
c.
Sexual history
d.
Growth measurements
e.
Nutritional assessment
f.
Family medical history
ANS: A, C, E, F
The review of systems, sexual history, nutritional assessment, and family medical history are part
of the health history. Physical assessment and growth measurements are components of the physical examination.
DIF: Cognitive Level: Apply
REF: p. 64
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is performing an assessment on a school-age child. Which findings suggest the child is
getting an excess of vitamin A? (Select all that apply.)
a.
b.
c.
d.
e.
Delayed sexual development
Edema
Pruritus
Jaundice
Paresthesia
ANS: A, C, D
Excess vitamin A can cause delayed sexual development, pruritus, and jaundice. Edema is seen
with excess sodium. Paresthesia occurs with excess riboflavin.
DIF: Cognitive Level: Apply
REF: p. 73
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is planning to use an interpreter during a health history interview of a non-English
speaking patient and family. Which nursing care guidelines should the nurse include when using
an interpreter? (Select all that apply.)
a.
Elicit one answer at a time.
b.
Interrupt the interpreter if the response from
the family is lengthy.
c.
Comments to the interpreter about the family
should be made in English.
d.
Arrange for the family to speak with the same
interpreter, if possible.
e.
Introduce the interpreter to the family.
ANS: A, D, E
When using an interpreter, the nurse should pose questions to elicit only one answer at a time,
such as: “Do you have pain?” rather than “Do you have any pain, tiredness, or loss of appetite?”
Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand
some English.
DIF: Cognitive Level: Apply
REF: p. 60
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. What is the correct sequence used when performing an abdominal assessment? Begin with the
first technique and end with the last. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).
a. Auscultation
b. Palpation
c. Inspection
d. Percussion
ANS:
c, a, d, b
The correct order of abdominal examination is inspection, auscultation, percussion, and palpation. Palpation is always performed last because it may distort the normal abdominal sounds.
DIF: Cognitive Level: Apply
REF: p. 104
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 05: Pain Assessment and Management in Children
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which
pain assessment tool should the nurse use to assess this child for the presence of pain?
a. FACES pain rating tool
b. Numeric scale
c. Oucher scale
d. FLACC tool
ANS: D
A behavioral pain tool should be used when the child is preverbal or doesn’t have the
language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool
should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all selfreport pain rating tools. Self-report measures are not sufficiently valid for children younger
than 3 years of age because many are not able to accurately self-report their pain.
DIF: Cognitive Level: Apply
REF: p. 115
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. The nurse is caring for a 6-year-old girl who had surgery 12 hours ago. The child tells the
nurse that she does not have pain, but a few minutes later she tells her parents that she does.
Which should the nurse consider when interpreting this?
a. Truthful reporting of pain should occur by this age.
b. Inconsistency in pain reporting suggests that pain is not present.
c. Children use pain experiences to manipulate their parents.
d. Children may be experiencing pain even though they deny it to the nurse.
ANS: D
Children may deny pain to the nurse because they fear receiving an injectable analgesic or
because they believe they deserve to suffer as a punishment for a misdeed. They may refuse
to admit pain to a stranger but readily tell a parent. Truthfully reporting pain and
inconsistency in pain reporting suggesting that pain is not present are common fallacies about
children and pain. Pain is whatever the experiencing person says it is, whenever the person
says it exists. Pain would not be questioned in an adult 12 hours after surgery.
DIF: Cognitive Level: Analyze
REF: p. 116
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
3. A nurse is gathering a history on a school-age child admitted for a migraine headache. The
child states, “I have been getting a migraine every 2 or 3 months for the last year.” The nurse
documents this as which type of pain?
a. Acute
b. Chronic
c. Recurrent
d. Subacute
ANS: C
Pain that is episodic and reoccurs is defined as recurrent pain. The time frame within which
episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine
headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain.
Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily
basis, for more than 3 months. Subacute is not a term for documenting type of pain.
DIF: Cognitive Level: Understand
REF: p. 118
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Physiologic Integrity
4. Physiologic measurements in children’s pain assessment are:
a. the best indicator of pain in children of all ages.
b. essential to determine whether a child is telling the truth about pain.
c. of most value when children also report having pain.
d. of limited value as sole indicator of pain.
ANS: D
Physiologic manifestations of pain may vary considerably, not providing a consistent measure
of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety,
or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or
stabilize. Physiologic measurements are of limited value and must be viewed in the context of
a pain-rating scale, behavioral assessment, and parental report. When the child states that pain
exists, it does. That is the truth.
DIF: Cognitive Level: Understand
REF: p. 119
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
5. Nonpharmacologic strategies for pain management:
a. may reduce pain perception.
b. make pharmacologic strategies unnecessary.
c. usually take too long to implement.
d. trick children into believing they do not have pain.
ANS: A
Nonpharmacologic techniques provide coping strategies that may help reduce pain
perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of
analgesics. Nonpharmacologic techniques should be learned before the pain occurs. With
severe pain, it is best to use both pharmacologic and nonpharmacologic measures for pain
control. The nonpharmacologic strategy should be matched with the child’s pain severity and
taught to the child before the onset of the painful experience. Some of the techniques may
facilitate the child’s experience with mild pain, but the child will still know the discomfort
was present.
DIF: Cognitive Level: Understand
REF: p. 124
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
6. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the
immediate postoperative period?
a. Codeine
b. Morphine
c. Methadone
d. Meperidine
ANS: B
The most commonly prescribed medications for PCA are morphine, hydromorphone, and
fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in
parenteral form in the United States. Meperidine is not used for continuous and extended pain
relief.
DIF: Cognitive Level: Remember
REF: p. 129
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. A lumbar puncture is needed on a school-age child. What should the nurse apply to provide
the most appropriate analgesia during this procedure?
TAC (tetracaine-adrenaline-cocaine) 15 minutes
Transdermal fentanyl (Duragesic) patch immediately
EMLA (eutectic mixture of local anesthetics) 1 hour
EMLA (eutectic mixture of local anesthetics) 30 minutes
a.
b.
c.
d.
ANS: C
EMLA is an effective analgesic agent when applied to the skin 60 minutes before a
procedure. It eliminates or reduces the pain from most procedures involving skin puncture.
TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel
can be placed on the wound for suturing. Transdermal fentanyl patches are useful for
continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be
applied approximately 60 minutes in advance.
DIF: Cognitive Level: Apply
REF: p. 143
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
8. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative
pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. What is
the priority nursing action?
a. Administer naloxone (Narcan)
b. Discontinue IV infusion
c. Discontinue morphine until child is fully awake
d. Stimulate child by calling name, shaking gently, and asking to breathe deeply
ANS: A
The management of opioid-induced respiratory depression includes lowering the rate of
infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be
aroused, then IV naloxone should be administered. The child will be in pain because of the
reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if
the child is unresponsive. The child is unresponsive, therefore naloxone is indicated.
DIF: Cognitive Level: Apply
REF: p. 143
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
9. The nurse is completing a pain assessment on a 4-year-old child. Which of the depicted pain
scale tools should the nurse use with a child this age?
a.
b.
c.
d.
ANS: A
The pain scale appropriate for a 4-year-old child is the FACES pain scale. Numeric pain
scales can be used on children as young as age 5 as long as they can count and have some
concept of numbers and their values in relation to other numbers. Word graphic scales and
visual analogue scales are used preferably for school-age children.
DIF: Cognitive Level: Analyze
REF: p. 115
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
10. Fentanyl and midazolam (Versed) are given before débridement of a child’s burn wounds.
Which is the rationale for administration of these medications?
a.
b.
c.
d.
Promote healing
Prevent infection
Provide pain relief
Limit amount of débridement that will be necessary
ANS: C
Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control
procedural pain in children with burns. These drugs are for sedation and pain control, not
healing, preventing infection, or limiting the amount of débridement.
DIF: Cognitive Level: Understand
REF: p. 127
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
11. Nitrous oxide is being administered to a child with extensive burn injuries. Which is the
purpose of this medication?
a. Promote healing
b. Prevent infection
c. Provide anesthesia
d. Improve urinary output
ANS: C
The use of short-acting anesthetic agents, such as propofol and nitrous oxide, has proven
beneficial in eliminating procedural pain. Nitrous oxide is an anesthetic agent.
DIF: Cognitive Level: Understand
REF: p. 144
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. A nurse recognizes which physiologic responses as a manifestation of pain in a neonate?
(Select all that apply.)
a. Decreased respirations
b. Diaphoresis
c. Decreased SaO2
d. Decreased blood pressure
e. Increased heart rate
ANS: B, C, E
The physiologic responses that indicate pain in neonates are increased heart rate, increased
blood pressure, rapid, shallow respirations, decreased arterial oxygen saturation (SaO2),
pallor or flushing, diaphoresis, and palmar sweating.
DIF: Cognitive Level: Apply
REF: p. 120
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is monitoring a patient for side effects associated with opioid analgesics. Which side
effects should the nurse expect to monitor for? (Select all that apply.)
a.
b.
c.
d.
e.
Diarrhea
Respiratory depression
Hypertension
Pruritus
Sweating
ANS: B, D, E
Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation
may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.
DIF: Cognitive Level: Understand
REF: p. 131
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
3. Which dietary recommendations should a nurse make to an adolescent patient to manage
constipation related to opioid analgesic administration? (Select all that apply.)
Bran cereal
Decrease fluid intake
Prune juice
Cheese
Vegetables
a.
b.
c.
d.
e.
ANS: A, C, E
To manage the side effect of constipation caused by opioids, fluids should be increased, and
bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a
nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause
constipation so it should not be recommended.
DIF: Cognitive Level: Apply
REF: p. 132
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
4. Surgery has informed a nurse that the patient returning to the floor after spinal surgery has an
opioid epidural catheter for pain management. The nurse should prepare to monitor the
patient for which side effects of an opioid epidural catheter? (Select all that apply.)
a. Urinary frequency
b. Nausea
c. Itching
d. Respiratory depression
ANS: B, C, D
Respiratory depression, nausea, itching, and urinary retention are dose-related side effects
from an epidural opioid. Urinary retention, not urinary frequency, would be seen.
DIF: Cognitive Level: Apply
REF: p. 132
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
SHORT ANSWER
1. A dose of oxycodone (OxyContin) 2 mg/kg has been ordered for a child weighing 33 lb. How
many milligrams of OxyContin should the nurse administer? (Record your answer as a whole
number.)
ANS:
30
The child’s weight is divided by 2.2 to get the weight in kilograms. Kilograms in weight are
then multiplied by the prescribed 2 mg. 33 lb/2.2 = 15 kg. 15 kg ´ 2 mg = 30 mg.
DIF: Cognitive Level: Apply
REF: p. 128
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the
following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense;
Cry: no cry; Consolability: content, relaxed. The nurse records the FLACC assessment as
which number? (Record your answer as a whole number.)
ANS:
2
The FLACC scale is recorded per the following table:
0
1
Face
No particular
Occasional grimace or
expression or
frown, withdrawn,
smile
disinterested
Legs
Normal position Uneasy, restless, tense
or relaxed
Activity
Lying quietly,
Squirming, shifting back
normal position, and forth, tense
moves easily
Cry
No cry (awake or Moans or whimpers,
asleep)
occasional complaint
2
Frequent to constant
frown, clenched jaw,
quivering chin
Kicking, or legs drawn up
Arched, rigid, or jerking
Crying steadily, screams
or sobs, frequent
complaints
Consolability Content, relaxed Reassured by occasional Difficult to console or
touching, hugging, or
comfort
talking to; distractible
Because the child has a grimace and is squirming and tense, 2 total points are given. Relaxed
legs, no cry, and content and relaxed consolability get 0 points.
DIF: Cognitive Level: Apply
REF: p. 141
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
OTHER
1. A patient on an intravenous opioid analgesic has become apneic. The nurse should implement
which interventions? Place the interventions in order from the highest priority (first
intervention) to the lowest priority (last intervention). Provide your answer using lowercase
letters separated by commas (e.g., a, b, c, d).
a. Place the patient on continuous pulse oximetry to assess SaO2.
b. Administer the prescribed naloxone (Narcan) dose by slow IV push.
c. Ensure oxygen is available.
d. Prepare to calm the child as analgesia is reversed.
ANS:
b, a, c, d
The Narcan prescribed dose should be given, first by slow IV push every 2 minutes until
effect is obtained. The second intervention should be assessment of the patient’s SaO2 status.
Oxygen should be made available and administered if the SaO2 status indicates hypoxemia.
Last, the child should be calmed as the analgesia is reversed.
DIF: Cognitive Level: Apply
REF: p. 135
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 06: Childhood Communicable and Infectious Diseases
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which term best describes the identification of the distribution and causes of disease, injury,
or illness?
a. Nursing process
b. Epidemiologic process
c. Community-based statistics
d. Mortality and morbidity statistics
ANS: B
Epidemiology is the science of population health applied to the detection of morbidity and
mortality in a population. It identifies the distribution and causes of diseases across a
population. Nursing process is a systematic problem-solving approach for the delivery of
nursing care. Morbidity and mortality statistics, along with natal rates, may provide an
objective picture of a community’s health status.
DIF: Cognitive Level: Remember
REF: p. 157
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. The nurse is taking care of a 7-year-old child with a skin rash called a papule. Which clinical
finding should the nurse expect to assess with this type of skin rash?
a. A lesion that is elevated, palpable, firm, and circumscribed; less than 1 cm in
diameter
b. A lesion that is elevated, flat-topped, firm, rough, and superficial; greater than 1
cm in diameter
c. An elevated lesion, firm, circumscribed, palpable; 1 to 2 cm in diameter
d. An elevated lesion, circumscribed, filled with serous fluid; less than 1 cm in
diameter
ANS: A
A papule is elevated; palpable; firm; circumscribed; less than 1 cm in diameter; and brown,
red, pink, tan, or bluish red. A plaque is an elevated, flat-topped, firm, rough, superficial
papule greater than 1 cm in diameter. It may be coalesced papules. A nodule is elevated, 1 to
2 cm in diameter, firm, circumscribed, palpable, and deeper in the dermis than a papule. A
vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with
serous fluid.
DIF: Cognitive Level: Understand
REF: p. 178
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is teaching nursing students about childhood skin lesions. Which is an elevated,
circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
a. Cyst
b. Papule
c. Pustule
d. Vesicle
ANS: D
A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with
serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid
or semisolid material. A papule is elevated, palpable, firm, circumscribed, less than 1 cm in
diameter, and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and
similar to a vesicle but filled with purulent fluid.
DIF: Cognitive Level: Remember
REF: p. 178
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical
finding should the nurse expect to assess with this type of lesion?
a. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in
diameter
b. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily,
varied in size
c. Flat, brown mole less than 1 cm in diameter
d. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
ANS: C
A macule is flat; nonpalpable; circumscribed; less than 1 cm in diameter; and brown, red,
purple, white, or tan. A patch is a flat, nonpalpable, and irregularly shaped macule that is
greater than 1 cm in diameter. Scale is heaped-up keratinized cells, flaky exfoliation,
irregular, thick or thin, dry or oily, varied in size, and silver white or tan. A plaque is an
elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be
coalesced papules.
DIF: Cognitive Level: Understand
REF: p. 178
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. Which nursing consideration is important when caring for a child with impetigo contagiosa?
a. Apply topical corticosteroids to decrease inflammation.
b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and
debris.
c. Carefully wash hands and maintain cleanliness when caring for an infected child.
d. Examine child under a Wood lamp for possible spread of lesions.
ANS: C
A major nursing consideration related to bacterial skin infections, such as impetigo
contagiosa, is to prevent the spread of the infection and complications. This is done by
thorough hand washing before and after contact with the affected child. Corticosteroids are
not indicated in bacterial infections. Dressings are usually not indicated. The undermined
skin, crusts, and debris are carefully removed after softening with moist compresses. A Wood
lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease
states, such as tinea capitis.
DIF: Cognitive Level: Understand
REF: p. 177
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse
what will happen to their child’s skin after the infection has subsided and healed. Which
answer should the nurse give?
a. There will be no scarring.
b. There may be some pigmented spots.
c. It is likely there will be some slightly depressed scars.
d. There will be some atrophic white scars.
ANS: A
Impetigo contagiosa tends to heal without scarring unless a secondary infection occurs.
DIF: Cognitive Level: Apply
REF: p. 177
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. What is cellulitis often caused by?
a. Herpes zoster
b. Candida albicans
c. Human papillomavirus
d. Streptococcus or Staphylococcus organisms
ANS: D
Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually
responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C.
albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with
various types of human warts.
DIF: Cognitive Level: Remember
REF: p. 176
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. The nurse is conducting a staff in-service on appearance of childhood skin conditions.
Lymphangitis (“streaking”) is frequently seen in which condition?
Cellulitis
Folliculitis
Impetigo contagiosa
Staphylococcal scalded skin
a.
b.
c.
d.
ANS: A
Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually required
for parenteral antibiotics. Lymphangitis is not associated with folliculitis, impetigo, or
staphylococcal scalded skin.
DIF: Cognitive Level: Understand
REF: p. 176
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. The nurse should expect to assess which causative agent in a child with warts?
a. Bacteria
b. Fungus
c. Parasite
d. Virus
ANS: D
Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and
parasites does not result in warts.
DIF: Cognitive Level: Understand
REF: p. 177
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. The nurse should implement which prescribed treatment for a child with warts?
a. Vaccination
b. Local destruction
c. Corticosteroids
d. Specific antibiotic therapy
ANS: B
Local destructive therapy individualized according to location, type, and number—including
surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment,
and laser therapies—is used. Vaccination is prophylaxis for warts and is not a treatment.
Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts.
DIF: Cognitive Level: Apply
REF: p. 178
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. Herpes zoster is caused by the varicella virus and has an affinity for:
a. sympathetic nerve fibers.
b. parasympathetic nerve fibers.
c. posterior root ganglia and posterior horn of the spinal cord.
d. lateral and dorsal columns of the spinal cord.
ANS: C
The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the
spinal cord, and skin. The zoster virus does not involve sympathetic or parasympathetic nerve
fibers and the lateral and dorsal columns of the spinal cord.
DIF: Cognitive Level: Understand
REF: p. 178
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. The nurse is taking care of a 7-year-old child with herpes simplex virus (type 1 or 2). Which
prescribed medication should the nurse expect to be included in the treatment plan?
Corticosteroids
Oral griseofulvin
Oral antiviral agent
Topical and/or systemic antibiotic
a.
b.
c.
d.
ANS: C
Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids
are not effective for viral infections. Griseofulvin is an antifungal agent and not effective for
viral infections. Antibiotics are not effective in viral diseases.
DIF: Cognitive Level: Apply
REF: p. 178
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. What causes tinea capitis (ringworm)?
a. Virus
b. Fungus
c. Allergic reaction
d. Bacterial infection
ANS: B
Ringworm is caused by a group of closely related filamentous fungi that invade primarily the
stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin.
Virus and bacterial infection are not the causative organisms for ringworm. Ringworm is not
an allergic response.
DIF: Cognitive Level: Understand
REF: p. 179
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. What
should the nurse expect the therapeutic management of this child to include?
Administering oral griseofulvin
Administering topical or oral antibiotics
Applying topical sulfonamides
Applying Burow solution compresses to affected area
a.
b.
c.
d.
ANS: A
Treatment with the antifungal agent griseofulvin is part of the treatment for the fungal disease
ringworm. Oral griseofulvin therapy frequently continues for weeks or months. Antibiotics,
sulfonamides, and Burow solution are not effective in fungal infections.
DIF: Cognitive Level: Understand
REF: p. 179
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. Parents tell the nurse that their child keeps scratching the areas where he has poison ivy. The
nurse’s response should be based on which knowledge?
a. Poison ivy does not itch and needs further investigation.
b. Scratching the lesions will not cause a problem.
c. Scratching the lesions will cause the poison ivy to spread.
d. Scratching the lesions may cause them to become secondarily infected.
ANS: D
Poison ivy is a contact dermatitis that results from exposure to the oil urushiol in the plant.
Every effort is made to prevent the child from scratching because the lesions can become
secondarily infected. The poison ivy produces localized, streaked or spotty, oozing, and
painful impetiginous lesions. Itching is a common response. Scratching the lesions can result
in secondary infections. The lesions do not spread by contact with the blister serum or by
scratching.
DIF: Cognitive Level: Apply
REF: p. 185
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. The nurse is taking care of a child with scabies. Which primary clinical manifestation should
the nurse expect to assess with this disease?
Edema
Redness
Pruritus
Maceration
a.
b.
c.
d.
ANS: C
Scabies is caused by the scabies mite. The inflammatory response and intense itching occur
after the host has become sensitized to the mite. This occurs approximately 30 to 60 days
after initial contact. Edema, redness, and maceration are not observed in scabies.
DIF: Cognitive Level: Understand
REF: p. 180
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. Which is usually the only symptom of pediculosis capitis (head lice)?
a. Itching
b. Vesicles
c. Scalp rash
d. Localized inflammatory response
ANS: A
Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is
made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and
localized inflammatory response are not symptoms of head lice.
DIF: Cognitive Level: Understand
REF: p. 182
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse
include when explaining how to manage pediculosis capitis?
a. “You will need to cut the hair shorter if infestation and nits are severe.”
b. “You can distinguish viable from nonviable nits, and remove all viable ones.”
c. “You can wash all nits out of hair with a regular shampoo.”
d. “You will need to remove nits with an extra-fine-tooth comb or tweezers.”
ANS: D
Treatment consists of the application of pediculicide and manual removal of nit cases. An
extra-fine-tooth comb facilitates manual removal. Parents should be cautioned against cutting
the child’s hair short; lice infest short hair as well as long. It increases the child’s distress and
serves as a continual reminder to peers who are prone to tease children with a different
appearance. It is not possible to differentiate between viable and nonviable eggs. Regular
shampoo is not effective; a pediculicide is necessary.
DIF: Cognitive Level: Apply
REF: p. 182
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
19. Which bite causes Rocky Mountain spotted fever?
a. Flea
b. Tick
c. Mosquito
d. Mouse or rat
ANS: B
Rocky Mountain spotted fever is caused by a tick. The tick must attach and feed for at least 1
to 2 hours to transmit the disease. The usual habitat of the tick is in heavily wooded areas.
Fleas, mosquitoes, and mice or rats do not transmit Rocky Mountain spotted fever.
DIF: Cognitive Level: Understand
REF: p. 186
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. The school nurse is conducting a class for school-age children on Lyme disease. Which is
characteristic of Lyme disease?
Difficult to prevent
Treated with oral antibiotics in stages 1, 2, and 3
Caused by a spirochete that enters the skin through a tick bite
Common in geographic areas where the soil contains the mycotic spores that cause
the disease
a.
b.
c.
d.
ANS: C
Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early
characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested
areas with caution. Light-colored clothing should be worn to identify ticks easily. Longsleeved shirts and long pants tucked into socks should be the attire. Early treatment of the
erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is
caused by a spirochete, not mycotic spores.
DIF: Cognitive Level: Understand
REF: p. 186
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
21. The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent
diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the
inguinal folds. What is most likely the cause of the diaper rash?
a. Impetigo
b. Candida albicans
c. Urine and feces
d. Infrequent diapering
ANS: B
C. albicans infection produces perianal inflammation and a maculopapular rash with satellite
lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads
peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact
with the diaper, but sparing the folds, are likely to be caused by chemical irritation, especially
urine and feces.
DIF: Cognitive Level: Analyze
REF: p. 179
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
22. A school nurse assesses a case of tinea capitis (ringworm) on a 6-year-old child. Which figure
depicts the characteristic lesion of tinea capitis?
a.
b.
c.
d.
ANS: C
Tinea capitis is characterized by lesions in the scalp configured of scaly, circumscribed
patches or patchy, scaling areas of alopecia. Generally the lesions are asymptomatic but a
severe, deep inflammatory reaction may occur that manifests as boggy, encrusted lesions
(kerions). Impetigo contagiosa is depicted in the figure showing the vesicular lesion around
the nares area that has become vesicular. The lesions rupture easily, leaving superficial, moist
erosions that tend to spread peripherally in sharply marginated irregular outlines. The exudate
dries to form heavy, honey-colored crusts. The figure depicting inflammation on the cheek is
cellulitis. Inflammation of skin and subcutaneous tissues is characterized by intense redness,
swelling, and firm infiltration. Cellulitis may progress to abscess formation. The figure
depicting “streaked blisters” surrounding one large blister is characteristic of contact
dermatitis from poison ivy contact.
DIF: Cognitive Level: Analyze
REF: p. 180
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. Airborne isolation is required for a child who is hospitalized with:
a. mumps.
b. chickenpox.
c. exanthema subitum (roseola).
d. erythema infectiosum (fifth disease).
ANS: B
Chickenpox is communicable through direct contact, droplet spread, and contaminated
objects. Mumps is transmitted from direct contact with saliva of infected person and is most
communicable before onset of swelling. The transmission and source of the viral infection
exanthema subitum (roseola) is unknown. Erythema infectiosum (fifth disease) is
communicable before onset of symptoms.
DIF: Cognitive Level: Understand
REF: p. 163
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment
24. Acyclovir (Zovirax) is given to children with chickenpox to:
a. minimize scarring.
b. decrease the number of lesions.
c. prevent aplastic anemia.
d. prevent spread of the disease.
ANS: B
Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching,
lethargy, and anorexia. Treating pruritus and discouraging itching minimize scarring. Aplastic
anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents
spread of disease.
DIF: Cognitive Level: Understand
REF: p. 163
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
25. The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the
nurse that she cannot afford to stay home with the child and miss work. The parent asks the
nurse if some medication will shorten the course of the illness. Which is the most appropriate
nursing intervention?
a. Reassure the parent that it is not necessary to stay home with the child.
b. Explain that no medication will shorten the course of the illness.
c. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
d. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat
chickenpox.
ANS: C
Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and
decreasing itching, lethargy, and anorexia. It is important the parent stay with the child to
monitor fever. Acyclovir lessens the severity of chickenpox. VariZIG is given only to highrisk children.
DIF: Cognitive Level: Apply
REF: p. 163
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
26. Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
a. Acyclovir (Zovirax)
b. Varicella globulin
c. Diphenhydramine hydrochloride (Benadryl)
d. VCZ immune globulin (VariZIG)
ANS: D
VariZIG is given to high-risk children to prevent the development of chickenpox. Acyclovir
decreases the severity, not the development, of chickenpox. Varicella globulin is not effective
because it is not the immune globulin. Diphenhydramine may help pruritus but not the actual
chickenpox.
DIF: Cognitive Level: Understand
REF: p. 163
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
27. Vitamin A supplementation may be recommended for the young child who has which
disease?
a. Mumps
b. Rubella
c. Measles (rubeola)
d. Erythema infectiosum
ANS: C
Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated
with analgesics for pain and antipyretics for fever. Rubella is treated similarly to mumps.
Erythema infectiosum is treated similarly to mumps and rubella.
DIF: Cognitive Level: Understand
REF: p. 166
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
28. A nurse is teaching parents about caring for their child with chickenpox. The nurse should let
the parents know that the child is considered to be no longer contagious when which occurs?
When fever is absent
When lesions are crusted
24 hours after lesions erupt
8 days after onset of illness
a.
b.
c.
d.
ANS: B
When the lesions are crusted, the chickenpox is no longer contagious. This may be a week
after onset of disease. Chickenpox is still contagious when child has fever. Children are
contagious after lesions erupt. If lesions are crusted at 8 days, the child is no longer
contagious.
DIF: Cognitive Level: Apply
REF: p. 163
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
29. A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases
are Koplik spots present?
Rubella
Measles (rubeola)
Chickenpox (varicella)
Exanthema subitum (roseola)
a.
b.
c.
d.
ANS: B
Koplik spots are small irregular red spots with a minute, bluish white center found on the
buccal mucosa 2 days before systemic rash. Rubella occurs with rash on the face, which
rapidly spreads downward. Varicella appears with highly pruritic macules, followed by
papules and vesicles. Roseola is seen with rose-pink macules on the trunk, spreading to face
and extremities.
DIF: Cognitive Level: Apply
REF: p. 166
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
30. Which is a common childhood communicable disease that may cause severe defects in the
fetus when it occurs in its congenital form?
Erythema infectiosum
Roseola
Rubeola
Rubella
a.
b.
c.
d.
ANS: D
Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in
contact with children affected with fifth disease. Roseola and rubeola are not dangerous to the
fetus.
DIF: Cognitive Level: Understand
REF: p. 168
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
31. Which is the causative agent of scarlet fever?
a. Enteroviruses
b. Corynebacterium organisms
c. Scarlet fever virus
d. Group A b-hemolytic streptococci (GABHS)
ANS: D
GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications.
Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.
DIF: Cognitive Level: Understand
REF: p. 169
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
32. A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with
purulent drainage and crusting of the eyelids, especially on awakening. These manifestations
suggest:
a. viral conjunctivitis.
b. allergic conjunctivitis.
c. bacterial conjunctivitis.
d. conjunctivitis caused by foreign body.
ANS: C
Bacterial conjunctivitis has these symptoms. Viral or allergic conjunctivitis has watery
drainage. Foreign body causes tearing and pain, and usually only one eye is affected.
DIF: Cognitive Level: Analyze
REF: p. 171
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity
33. Which is an important nursing consideration when caring for a child with herpetic
gingivostomatitis (HGS)?
Apply topical anesthetics before eating.
Drink from a cup, not a straw.
Wait to brush teeth until lesions are sufficiently healed.
Explain to parents how this is sexually transmitted.
a.
b.
c.
d.
ANS: A
Treatment for HGS is aimed at relief of pain. Drinking bland fluids through a straw helps
avoid painful lesions. Mouth care is encouraged with a soft toothbrush. HGS is usually
caused by herpes simplex virus type 1, which is not associated with sexual transmission.
DIF: Cognitive Level: Apply
REF: p. 172
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
34. A parent has asked the nurse about how her child can be tested for pinworms. The nurse
responds by stating that which is the most common test for diagnosing pinworms in a child?
Lower gastrointestinal (GI) series
Three stool specimens, at intervals of 4 days
Observation for presence of worms after child defecates
Laboratory examination of a fecal smear
a.
b.
c.
d.
ANS: D
Laboratory examination of substances containing the worm, its larvae, or ova can identify the
organism. Most are identified by examining fecal smears from the stools of persons suspected
of harboring the parasite. Fresh specimens are best for revealing parasites or larvae. Lower GI
series is not helpful for diagnosing enterobiasis. Stool specimens are not necessary to
diagnose pinworms. Worms will not be visible after child defecates.
DIF: Cognitive Level: Understand
REF: p. 174
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
35. A clinic nurse is assessing a child with erythema infectiosum (fifth disease). Which figure
depicts the rash the nurse should expect to assess?
a.
b.
c.
d.
ANS: A
Erythema infectiosum rash appears in three stages: erythema on face, chiefly on cheeks
(“slapped face” appearance); disappears by 1-4 days. Chicken pox rash begins as macule,
rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes
umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle,
crust) present in varying degrees at one time. Roseola rash is discrete rose-pink macules or
maculopapules appearing first on trunk and then spreading to neck, face, and extremities;
nonpruritic; fades on pressure; lasts 1-2 days. Rubeola rash—appears 3-4 days after onset of
prodromal stage; begins as erythematous maculopapular eruption on face and gradually
spreads downward; more severe in earlier sites (appears confluent) and less intense in later
sites (appears discrete); after 3-4 days, assumes brownish appearance, and fine desquamation
occurs over area of extensive involvement.
DIF: Cognitive Level: Apply
REF: p. 164
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
36. A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication
should the nurse expect to be prescribed?
a. Metronidazole (Flagyl)
b. Amoxicillin clavulanate (Augmentin)
c. Clarithromycin (Biaxin)
d. Prednisone (Orapred)
ANS: A
The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole
(Tindamax), and nitazoxanide (Alinia). These are classified as antifungals. Amoxicillin and
clarithromycin are antibiotics that treat bacterial infections. Prednisone is a steroid and is
used as an anti-inflammatory medication.
DIF: Cognitive Level: Apply
REF: p. 174
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
37. A mother tells the nurse that she does not want her infant immunized because of the
discomfort associated with injections. What should the nurse explain?
a. This cannot be prevented.
b. Infants do not feel pain as adults do.
c. This is not a good reason for refusing immunizations.
d. A topical anesthetic, EMLA, can be applied before injections are given.
ANS: D
Several topical anesthetic agents can be used to minimize the discomfort associated with
immunization injections. These include EMLA (eutectic mixture of local anesthetic) and
vapor coolant sprays. Pain associated with many procedures can be prevented and minimized
by using the principles of atraumatic care. With preparation, the injection site can be properly
anesthetized to decrease the amount of pain felt by the infant. Infants have the neural
pathways to feel pain. Numerous research studies have indicated that infants perceive and
react to pain in the same manner as do children and adults. The mother should be allowed to
discuss her concerns and the alternatives available. This is part of the informed consent
process.
DIF: Cognitive Level: Apply
REF: p. 151
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The community health nurse is teaching parents about prevention of the spread and
reoccurrence of pediculosis (head lice). Which should the nurse include in the teaching
session? (Select all that apply.)
a. Dryclean nonwashable items.
b. Spray the environment with an insecticide.
c. Seal nonwashable items in a plastic bag for 5 days.
d. Boil combs and brushes for 10 minutes.
e. Discourage sharing of personal items.
ANS: A, D, E
To prevent the spread and reoccurrence of pediculosis the nurse should teach the parents to:
dryclean nonwashable items, boil combs and brushes for 10 minutes or soak for 1 hour in a
pediculicide, and discourage the sharing of personal items, such as combs, hats, scarves and
other headgear. Spraying with insecticide is not recommended because of the danger to
children and animals. Nonwashable items should be sealed for 14 days in a plastic bag.
DIF: Cognitive Level: Apply
REF: p. 182
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. A nurse is preparing to administer routine immunizations to a 4-month-old infant. The infant
is currently up to date on all previously recommended immunizations. Which immunizations
will the nurse prepare to administer? (Select all that apply.)
a. Measles, mumps, and rubella (MMR)
b. Rotavirus (RV)
c. Diphtheria, tetanus, pertussis (DTaP)
d. Varicella
e. Haemophilus influenzae type b (HIB)
f. Inactivated poliovirus (IPV)
ANS: B, C, E, F
Recommended immunization schedule for a 4-month-old, up to date on immunizations,
would be to administer the rotavirus (RV), diphtheria, tetanus, pertussis (DTaP),
Haemophilus influenza type b (HIB), and inactivated poliovirus (IPV) vaccinations. The
measles, mumps, and rubella (MMR) and varicella would not be administered until the child
is at least 1 year of age.
DIF: Cognitive Level: Apply
REF: p. 151
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 07: Health Promotion of the Newborn and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which is the most critical physiologic change required of the newborn?
a. Closure of fetal shunts in the heart
b. Stabilization of fluid and electrolytes
c. Body-temperature maintenance
d. Onset of breathing
ANS: D
The onset of breathing is the most immediate and critical physiologic change required for
transition to extrauterine life. Factors that interfere with this normal transition increase fetal
asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. This affects the
fetus’s adjustment to extrauterine life. Closure of fetal shunts in the heart, stabilization of
fluid and electrolytes, and body-temperature maintenance are important changes that must
occur in the transition to extrauterine life, but breathing and the exchange of oxygen for
carbon dioxide must come first.
DIF: Cognitive Level: Understand
REF: p. 190
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which is a function of brown adipose tissue (BAT) in the newborn?
a. Provides ready source of calories in the newborn period
b. Insulates the body against lowered environmental temperature
c. Protects the newborn from injury during the birth process
d. Generates heat for distribution to other parts of body
ANS: D
Brown fat is a unique source of heat for the newborn. It has a larger content of mitochondrial
cytochromes and a greater capacity for heat production through intensified metabolic activity
than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of
the body by the blood. It is effective in heat production only. The newborn has a thin layer of
subcutaneous fat, which does not provide for conservation of heat. Brown fat is located in
superficial areas such as between the scapulae, around the neck, in the axillae, and behind the
sternum. These areas would not protect the newborn from injury during the birth process.
DIF: Cognitive Level: Understand
REF: p. 191
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which characteristic is representative of the newborn’s gastrointestinal tract?
a. Stomach capacity is approximately 90 ml.
b. Peristaltic waves are relatively slow.
c. Overproduction of pancreatic amylase occurs.
d. Intestines are shorter in relation to body size.
ANS: A
Newborns require frequent small feedings because their stomach capacity is approximately
90 ml. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of
fats. Newborn’s intestines are longer in relation to body size than those of an adult.
DIF: Cognitive Level: Understand
REF: p. 191
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe
this type of stool?
Meconium
Transitional
Miliaria
Milk stool
a.
b.
c.
d.
ANS: A
Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed
mucosal cells, and possibly blood. It is the newborn’s first stool. Transitional stools usually
appear by the third day after the beginning of feeding. They are usually greenish brown to
yellowish brown, thin, and less sticky than meconium. Miliaria are distended sweat glands
that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth
day. The appearance varies, depending on whether the neonate is breastfed or formula-fed.
DIF: Cognitive Level: Remember
REF: p. 191
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse
documents this finding and continues to monitor the newborn because, in term newborns, the
first meconium stool occurs within how many hours of birth?
a. 6 to 8
b. 8 to 12
c. 12 to 24
d. 24 to 48
ANS: D
The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to
7 days in very low birth weight newborns. Although it may occur earlier, the expected range
is the first 24 to 48 hours of life.
DIF: Cognitive Level: Remember
REF: p. 191
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A nurse is doing an assessment on a newborn. Which is characteristic of a newborn’s vision at
birth and an expected finding during the assessment?
Ciliary muscles are mature.
Blink reflex is absent.
Tear glands function.
Pupils react to light.
a.
b.
c.
d.
ANS: D
Although at birth the eye is still structurally incomplete, the pupils do react to light. The
ciliary muscles are immature, limiting the eyes’ ability to focus on an object for any length of
time. The blink reflex is responsive to minimal stimulus. The tear glands do not begin to
function until ages 2 to 4 weeks.
DIF: Cognitive Level: Remember
REF: p. 193
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. The Apgar score of a newborn 5 minutes after birth is 8. Which is the nurse’s best
interpretation of this?
a. Resuscitation is likely to be needed.
b. Adjustment to extrauterine life is adequate.
c. Additional scoring in 5 more minutes is needed.
d. Maternal sedation or analgesia contributed to the low score.
ANS: B
The Apgar reflects the newborn’s status in five areas: heart rate, respiratory effort, muscle
tone, reflex irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting
to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 6 indicate
moderate difficulty. The Apgar score is not used to determine the newborn’s need for
resuscitation at birth. All newborns are rescored at 5 minutes. The newborn does not have a
low score.
DIF: Cognitive Level: Understand
REF: p. 193
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. The nurse is presenting an in-service session on assessing gestational age in newborns. Which
information should be included?
a. The newborn’s length and weight are the most accurate indicators of gestational
age.
b. The newborn’s Apgar score and the mother’s estimated date of confinement (EDC)
are combined to determine gestational age.
c. The newborn’s posture at rest and arm recoil are two physical signs used to
determine gestational age.
d. The newborn’s chest circumference compared to the head circumference is the
determinant for gestational age.
ANS: C
With the newborn quiet and in a supine position, the degree of flexion in the arms and legs
and the arm recoil can be used to help determine gestational age. Length, weight, and the
chest/head circumference reflect the newborn’s size and weight, which vary according to race
and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The
Apgar score is an indication of the newborn’s adjustment to extrauterine life, and the
mother’s EDC is of no importance in determining gestational age.
DIF: Cognitive Level: Apply
REF: p. 193
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. The nurse is assessing a 3-day-old, breastfed newborn who weighed 7 pounds, 8 ounces at
birth. The newborn’s mother is now concerned that the newborn weighs 6 pounds, 15 ounces.
Which is the most appropriate nursing intervention?
a. Recommend supplemental feedings of formula.
b. Explain that this weight loss is within normal limits.
c. Assess child further to determine cause of excessive weight loss.
d. Encourage mother to express breast milk for bottle feeding the newborn.
ANS: B
The newborn normally loses about 10% of the birth weight by age 3 or 4 days. The birth
weight is usually regained by the tenth day of life. Because this is an expected occurrence, no
further action is needed. The mother should be taught about normal newborn feeding and
growing patterns.
DIF: Cognitive Level: Apply
REF: p. 196
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Why are rectal temperatures not recommended in the newborn?
a. They are inaccurate.
b. They do not reflect core body temperature.
c. They can cause perforation of rectal mucosa.
d. They take too long to obtain an accurate reading.
ANS: C
Rectal temperatures are avoided in the newborn. If done incorrectly, the insertion of a
thermometer into the rectum can perforate the mucosa. Rectal temperatures, if taken
correctly, are considered an accurate reflection of core body temperature. The inherent risks
and intrusive nature limit the use. The time it takes to determine body temperature is related
to the equipment used, not the route only.
DIF: Cognitive Level: Remember
REF: p. 197
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
a. 60 to 80 beats/min
b. 80 to 100 beats/min
c. 120 to 140 beats/min
d. 160 to 180 beats/min
ANS: C
The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is
between 120 and 140 beats/min; 60 to 100 beats/min is too slow for a neonate and 160 to 180
beats/min is too fast for a neonate.
DIF: Cognitive Level: Remember
REF: p. 197
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. A nurse is palpating a newborn’s fontanels. The nurse documents the anterior fontanel is
which shape?
a. Circle
b. Triangle
c. Square
d. Diamond
ANS: D
The anterior fontanel is diamond-shaped and measures from barely palpable to 4 to 5 cm.
Neither of the fontanels is a circle or a square. The triangle is the shape of the posterior
fontanel.
DIF: Cognitive Level: Understand
REF: p. 198
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
13. Which is the name of the suture separating the parietal bones at the top center of a newborn’s
head?
Frontal
Coronal
Sagittal
Occipital
a.
b.
c.
d.
ANS: C
The sagittal suture separates the parietal bones on top of the newborn’s head. The frontal
suture separates the frontal bones. The coronal suture is said to “crown the head.” There is no
occipital suture. The lambdoid suture is at the margin of the parietal and occipital bones.
DIF: Cognitive Level: Remember
REF: p. 198
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
14. In a newborn’s eyes, strabismus is a normal finding because of:
a. congenital cataracts.
b. lack of binocularity.
c. absence of red reflex.
d. inability of pupil to react to light.
ANS: B
Newborns are unable to focus their eyes on an object. Binocularity does not develop until
ages 3 to 4 months. Congenital cataracts, absence of red reflex, and inability of pupil to react
to light are not normal findings and need further evaluation.
DIF: Cognitive Level: Understand
REF: p. 199
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A nurse has determined that a newborn’s respiratory breathing is within a normal range. How
should the nurse document this finding?
Irregular, abdominal, 30 to 60 breaths/min
Regular, abdominal, 25 to 35 breaths/min
Regular, noisy, 35 to 45 breaths/min
Irregular, quiet, 45 to 55 breaths/min
a.
b.
c.
d.
ANS: A
The respirations of a normal newborn are irregular and abdominal, with a rate of 30 to 60
breaths/min. Newborn respirations are irregular. Pauses in respiration less than 20 seconds in
duration are considered normal. The newborn is an abdominal breather with a wider range of
respiratory rates.
DIF: Cognitive Level: Understand
REF: p. 197
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
16. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large,
edematous, and pendulous. This should be interpreted as a(n):
a. normal finding.
b. hydrocele.
c. absence of testes.
d. inguinal hernia.
ANS: A
A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a
breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral,
which usually resolves within a few months. The presence or absence of testes would be
determined on palpation of the scrotum and inguinal canal. Absence of testes may be an
indication of ambiguous genitalia. An inguinal hernia may be present at birth. It is more
easily detected when the child is crying.
DIF: Cognitive Level: Apply
REF: p. 201
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the
head toward that side and begin to suck. This is which reflex?
Perez
Sucking
Rooting
Extrusion
a.
b.
c.
d.
ANS: C
Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the
head toward that side and begin to suck is a description of the rooting reflex, which usually
disappears by ages 3 to 4 months but may persist for up to 12 months. The Perez reflex
involves stroking the newborn’s back when prone; the child flexes extremities, elevating head
and pelvis. It disappears at ages 4 to 6 months. The newborn begins strong sucking
movements in response to circumoral stimulation. The reflex persists throughout infancy,
even without stimulation. Newborns force their tongues outward, when the tongue is touched
or depressed. This reflex usually disappears by age 4 months.
DIF: Cognitive Level: Understand
REF: p. 203
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Which statement best represents the first stage of the first period of reactivity in the newborn?
a. It begins when the newborn awakes from a deep sleep.
b. It ends when the amount of respiratory mucus has decreased.
c. It is an excellent time to acquaint the parents with the newborn.
d. It is an excellent time for mother to sleep and recover.
ANS: C
During the first period of reactivity, the newborn is alert, cries vigorously, may suck the fist
greedily, and appears interested in the environment. The newborn’s eyes are usually wide
open, suggesting that this is an excellent opportunity for mother, father, and child to see each
other. The second period of reactivity begins when the newborn awakens from a deep sleep.
The second period of reactivity ends when the amount of respiratory mucus has decreased.
The mother should sleep and recover during the second stage, when the newborn is sleeping.
DIF: Cognitive Level: Understand
REF: p. 202
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
19. The nurse observes that a new mother avoids making eye contact with her newborn. The
nurse should perform which action?
Examine newborn’s eyes for ability to focus.
Assess for other attachment behaviors.
Recognize this as a common reaction in new mothers.
Ask mother why she won’t look at newborn.
a.
b.
c.
d.
ANS: B
Attachment behaviors are thought to indicate the formation of emotional bonds between the
newborn and the mother. The mother’s failure to make eye contact with her newborn may
indicate difficulties with the formation of emotional bonds. The nurse should perform a more
thorough assessment. Newborns do not have binocularity and cannot focus. It is uncommon
for a mother to avoid making eye contact with her newborn and it is confrontational to ask
why; this would put the mother in a defensive position.
DIF: Cognitive Level: Apply
REF: p. 205
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
20. At the time of birth, what is the grayish white, cheeselike substance that normally covers the
newborn’s skin called?
Miliaria
Meconium
Amniotic fluid
Vernix caseosa
a.
b.
c.
d.
ANS: D
The grayish white, cheeselike substance that normally covers the newborn’s skin is the vernix
caseosa. Miliaria are distended sweat glands that appear as minute vesicles. Meconium is the
newborn’s first stool. Amniotic fluid is produced in utero.
DIF: Cognitive Level: Remember
REF: p. 206
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
21. What are distended sebaceous glands that appear as tiny white papules on cheeks, chin, and
nose in the newborn period called?
a. Milia
b. Lanugo
c. Mongolian spots
d. Cutis marmorata
ANS: A
Distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the
newborn period are milia, which are common variations found in newborns. Lanugo is fine
downy hair. Mongolian spots are irregular areas of deep blue pigmentation, usually in the
sacral and gluteal areas. Cutis marmorata is transient mottling when the newborn is exposed
to decreased body temperatures.
DIF: Cognitive Level: Remember
REF: p. 206
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
22. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
a. Feet and hands
b. Bridge of nose
c. Circumoral area
d. Mucous membranes
ANS: A
Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns.
Cyanosis present at the bridge of the nose, the circumoral area, and the mucous membranes is
a potential sign of distress or major abnormality.
DIF: Cognitive Level: Analyze
REF: p. 206
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
23. What term describes irregular areas of deep blue pigmentation seen predominantly in
newborns of African, Asian, Native American, or Hispanic descent?
a. Acrocyanosis
b. Erythema toxicum
c. Mongolian spots
d. Harlequin color changes
ANS: C
Irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian,
Native American, or Hispanic descent are Mongolian spots, which are common variations
found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is
cyanosis of the hands and feet that is a usual finding in newborns. Erythema toxicum consists
of pink papular vesicles that may appear in 24 to 48 hours and resolve after several days.
Harlequin color changes are clearly outlined areas of color change. As the newborn lies on
one side, the lower half of the body becomes pink and the upper half is pale.
DIF: Cognitive Level: Understand
REF: p. 206
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
24. The nurse observes flaring of nares in a newborn. This should be interpreted as:
a. nasal occlusion.
b. sign of respiratory distress.
c. common response to sneezing.
d. snuffles of congenital syphilis.
ANS: B
Nasal flaring is an indication of respiratory distress. A nasal occlusion would prevent the
child from breathing through the nose. Because newborns are obligatory nose breathers, this
would require immediate referral. Sneezing and thin white mucus drainage are common in
newborns and are not related to nasal flaring. Snuffles are indicated by a thick, bloody, nasal
discharge without sneezing.
DIF: Cognitive Level: Understand
REF: p. 207
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
25. A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
a. Nystagmus
b. Profuse drooling
c. Dark green or black stools
d. Slight vaginal reddish discharge
ANS: B
Profuse drooling or salivation is a potential sign of a major abnormality. Newborns with
esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling.
Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns.
Meconium, the first stool of newborns, is dark green or black. Pseudomenstruation may be
present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
DIF: Cognitive Level: Understand
REF: p. 207
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
26. Which is most important in the immediate care of the newborn?
a. Maintain patent airway.
b. Maintain stable body temperature.
c. Administer prophylactic eye care.
d. Establish identification of mother and baby.
ANS: A
Maintaining a patent airway is the primary objective in the care of the newborn. The nurse
uses a bulb syringe to clear the pharynx, followed by the nasal passages. Conserving the
newborn’s body heat and maintaining a stable body temperature are important, but a patent
airway must be established first. These are important functions, but physiologic stability is
the first priority in the immediate care of the newborn.
DIF: Cognitive Level: Analyze
REF: p. 210
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
27. The nurse is careful to place the incubator away from cold windows or air-conditioning units.
This is to conserve the newborn’s body heat by preventing heat loss through:
radiation.
conduction.
convection.
evaporation.
a.
b.
c.
d.
ANS: A
Radiation is the loss of heat to a cooler solid object. The cold air from either the window or
the air conditioner will cool the incubator walls and subsequently the newborn’s body.
Conduction involves the loss of heat from the body because of direct contact of the skin with
a cooler object. Convection is the loss of heat similar to conduction but aided by air currents.
Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the
amniotic fluid.
DIF: Cognitive Level: Apply
REF: p. 210
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
28. Parents of a newborn ask the nurse why vitamin K is being administered. The nurse
accurately responds by explaining phytonadione (vitamin K) is administered to the newborn
to:
a. prevent bleeding.
b. enhance immune response.
c. prevent bacterial infection.
d. maintain nutritional status.
ANS: A
Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is
synthesized by the intestinal flora. Because the newborn’s intestine is sterile and breast milk
is low in vitamin K, a supplemental source must be supplied. The purpose is not to enhance
the immune response, prevent bacterial infection, or maintain nutritional status. The major
function of vitamin K is to catalyze the liver synthesis of prothrombin, which is needed for
blood clotting and coagulation.
DIF: Cognitive Level: Apply
REF: p. 211
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
29. In the newborn, intramuscular phytonadione (vitamin K) is administered into which muscle?
a. Deltoid
b. Dorsogluteal
c. Vastus medialis
d. Vastus lateralis
ANS: D
The vastus lateralis is the traditionally recommended injection site. The deltoid and
dorsogluteal sites are not recommended for the vitamin K administration. The ventrogluteal
may be used as an alternative site to the vastus lateralis. The vastus medialis is not used for
intramuscular injections.
DIF: Cognitive Level: Apply
REF: p. 211
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
30. Recommendations for hepatitis B (HBV) vaccine include which statement?
a. First dose is given between birth and age 2 days.
b. First dose is given between ages 12 and 15 months.
c. It is not recommended for neonates who are at low risk for hepatitis B.
d. It is not recommended for neonates whose mothers are positive for HBV surface
antigen.
ANS: A
To reduce the incidence of HBV in children and its serious consequences in adulthood, the
first of three doses is recommended soon after birth and before hospital discharge. Between
12 and 15 months is too late. The recommendation is for the first dose to be given soon after
birth. It is recommended for all newborns. Newborns born to mothers who are HBV surface
antigen positive should be given the vaccine within 12 hours of birth. They also should be
given hepatitis B immune globulin.
DIF: Cognitive Level: Understand
REF: p. 211
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
31. A newborn is being discharged at age 48 hours. The parents ask how the newborn should be
bathed this first week home. How should the nurse recommend to bathe the newborn?
a. Daily with mild soap
b. Daily with an alkaline soap
c. Two or three times this week with plain water
d. Two or three times this week with mild soap
ANS: C
The newborn newborn’s skin has a pH of approximately 5. This acidic pH has a bacteriostatic
effect. The parents should be taught to use only plain warm water for the bath and to bathe
the child no more than two or three times a week for the first 2 weeks. Soaps are alkaline.
They will alter the acid mantle of the child’s skin, providing a medium for bacterial growth.
DIF: Cognitive Level: Apply
REF: p. 213
TOP: Integrated Process: Teaching/Learning | Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
32. The stump of the umbilical cord usually separates in how many days?
a. 3
b. 10 to 14
c. 16 to 20
d. 28
ANS: B
The average cord separates in 10 to 14 days; 3 days is too soon and 16 to 28 days is too late.
The cord should be separated by these times.
DIF: Cognitive Level: Remember
REF: p. 213
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
33. The parents of a newborn plan to have him circumcised. They ask the nurse about pain
associated with this procedure. What knowledge should the nurse’s response be based on?
a. Experience pain with circumcision
b. Do not experience pain with circumcision
c. Quickly forget about the pain of circumcision
d. Are too young for anesthesia or analgesia
ANS: A
Circumcision is a surgical procedure. The American Academy of Pediatrics has
recommended that, when circumcision is performed, procedural analgesia be provided. Pain
is associated with surgical procedures. The newborn experiences pain, which can be
alleviated with analgesia. Topical and injected analgesia are available for this procedure.
DIF: Cognitive Level: Apply
REF: p. 214
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
34. Early this morning, a baby boy was circumcised by using the Plastibell method. When should
the nurse tell the mother that the baby can be discharged?
The newborn voids
Receiving vitamin K
Yellow exudate forms over glans
The Plastibell rim falls off
a.
b.
c.
d.
ANS: A
The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2
hours. After these observations and voiding, the newborn can be discharged. The newborn
should have received vitamin K soon after delivery. This normal yellow exudate will usually
form on the second day after the circumcision. Discharge can occur earlier. The Plastibell rim
will separate and fall off within 5 to 8 days. The newborn should be discharged before this.
DIF: Cognitive Level: Apply
REF: p. 215
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
35. What does the American Academy of Pediatrics recommend as the best form of newborn
nutrition?
Exclusive breastfeeding until age 2 months.
Exclusive breastfeeding until age 6 months.
Commercially prepared newborn formula for 1 year.
Commercially prepared newborn formula until age 4 to 6 months.
a.
b.
c.
d.
ANS: B
The American Academy of Pediatrics has reaffirmed its position that a newborn be breastfed
exclusively for the first six months of life. This group also supports programs that enable
women to return to work and continue breastfeeding. Two months is too short of a period.
The recommendation is for breastfeeding, not commercial formula. If the mother has stopped
breastfeeding, then commercial formula, rather than whole milk, should be used until age 1
year.
DIF: Cognitive Level: Understand
REF: p. 216
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
36. On what is successful breastfeeding most dependent?
a. Mother’s socioeconomic level
b. Size of mother’s breasts
c. Mother’s desire to breastfeed
d. Birth weight of newborn
ANS: C
The factors that contribute to successful breastfeeding are the mother’s desire to breastfeed,
satisfaction with breastfeeding, and available support systems. The mother’s socioeconomic
level may affect the mother’s need to return to work and available support systems, but with
support, the mother can be successful. The size of the mother’s breasts does not affect the
success of breastfeeding. Very low birth weight newborns may be unable to breastfeed. The
mother can express milk, and it can be used for the child.
DIF: Cognitive Level: Apply
REF: p. 216
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
37. What should a nursing intervention to promote parent-newborn attachment include?
a. Delaying parent-newborn interactions until the second period of reactivity
b. Explaining individual differences among newborns to the parents
c. Alleviating stress for parents by decreasing their participation in the newborn’s
care
d. Allowing a newborn to fuss for a period of time before soothing by holding
ANS: B
Nurses can positively influence the attachment of parent and child by recognizing and
explaining individual differences to the parents. The nurse should emphasize the normalcy of
these variations and demonstrate the uniqueness of each newborn. The nurse should facilitate
parent-newborn interaction during the first period of reactivity. Decreasing the parents’
participation in care will interfere with parent-newborn attachment. The parents should be
encouraged to hold the newborn when he or she is fussy and learn how best to soothe their
newborn.
DIF: Cognitive Level: Apply
REF: p. 221
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
38. A new mother wants to be discharged with her newborn as soon as possible. What should be
done prior to discharge?
Newborn has voided at least once
Newborn does not spit up after feeding
Jaundice, if present, appeared before 24 hours
Appointment is made for home care or a primary care practitioner office visit
within next 2 or 3 days
a.
b.
c.
d.
ANS: D
The American Academy of Pediatrics recommends that newborns discharged early receive
follow-up care within 48 hours of a short stay in either a primary practitioner’s office or the
home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is a
normal occurrence in newborns. It would not delay discharge. Jaundice within the first 24
hours of life must be evaluated.
DIF: Cognitive Level: Apply
REF: p. 224
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
39. What should nursing interventions to maintain a patent airway in a newborn include?
a. Sleeping in the prone (on abdomen) position
b. Wrapping neonate as snugly as possible
c. Positioning neonate supine while sleeping
d. Using bulb syringe to suction as needed, suctioning nose first, and then pharynx
ANS: C
Supine is the position recommended by the American Academy of Pediatrics to prevent
sudden infant death syndrome. Sleeping in the prone position is not advised because of the
possible link between sleeping in the prone position and sudden infant death syndrome. The
child can be wrapped snugly, but should be placed on side or back. A bulb syringe should be
kept by the bedside if necessary, but the pharynx should be suctioned before the nose.
DIF: Cognitive Level: Apply
REF: p. 210
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
40. A nurse is assessing the presence of expected reflexes in a newborn. Which figure depicts the
elicitation of the tonic neck reflex?
a.
b.
c.
d.
ANS: B
The tonic neck reflex is elicited when the newborn’s head is turned to one side; the arm and
leg extend on that side, and opposite arm and leg flex (fencing position). The Moro reflex is
elicited by sudden jarring or change in equilibrium. The newborn has extension and
abduction of extremities and fanning of fingers, with index finger and thumb forming a C
shape followed by flexion and adduction of extremities; legs may weakly flex. The dancing
reflex is elicited when the newborn is held so that the sole of the foot touches a hard surface;
there is a reciprocal flexion and extension of the leg, simulating walking. The crawl reflex is
elicited when the newborn is placed on the abdomen; the newborn makes crawling
movements with arms and legs.
DIF: Cognitive Level: Analyze
REF: p. 204
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications
for breastfeeding? (Select all that apply.)
Human immunodeficiency virus (HIV) in mother
Mastitis
Inverted nipples
Maternal cancer therapy
Twin births
a.
b.
c.
d.
e.
ANS: A, D
HIV in the mother and maternal cancer therapy place the newborn at risk. HIV can be
transmitted through breast milk, as can be the metabolites of chemotherapy. Mastitis, inverted
nipples, and twin births are not contraindications.
DIF: Cognitive Level: Apply
REF: p. 216
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse is conducting discharge teaching for parents of a newborn. The nurse instructs the
parents on which method of care for the umbilical cord? (Select all that apply.)
a. Covering the cord with the diaper
b. Cleansing the cord with water daily
c. Keeping the cord area free of urine and stool
d. Monitoring for signs of infection
e. Applying bacitracin ointment to the cord daily
ANS: B, C, D
Parents are taught to keep the cord area free of urine and stool, cleanse daily with water if
needed, and observe for any signs of infection. The diaper should not cover the cord. The
diaper is folded in front below the cord to avoid irritation and wetness on the site. Bacitracin
ointment should not be applied because the cord area should be kept dry, not moist.
DIF: Cognitive Level: Apply
REF: p. 225
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed.
Which should the nurse include in the teaching session? (Select all that apply.)
a. Limiting the feeding to 15 minutes
b. Propping the bottle for night feedings is acceptable
c. Proper technique for cleansing the bottles and nipples
d. Feeding infant on alternate sides of the lap
e. Use of bottled water without fluoride should be avoided to mix powdered formula.
ANS: C, D, E
Parents preparing infant formula must wash their hands well and then wash all of the
equipment used to prepare the formula (including the cans of formula) with soap and water.
Sterilizing bottles and nipples 5 minutes in boiling water may be required when a hot-water
dishwasher is not available. Similar to breastfed infants, bottle-fed infants need to be held on
alternate sides of the lap to expose them to different stimuli. Bottled water should not be
considered sterile unless otherwise indicated; bottled water without fluoride should be
avoided for mixing infant formula. Propping the bottle during infant feedings at nighttime
could cause the infant to aspirate. The feeding should not be hurried. Even though they may
suck vigorously for the first 5 minutes and seem to be satisfied, infants should be allowed to
continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per
day, then about 20 minutes of sucking at each feeding provide for oral gratification.
DIF: Cognitive Level: Apply
REF: p. 218
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is performing a gestational age assessment on a newborn. The nurse determines that
the newborn is “term” if which findings are assessed? (Select all that apply.)
Posture with fully flexed arms and legs
Arm recoil brisk
Square window at 90 degrees
Scarf sign of elbow crossing over the midline
a.
b.
c.
d.
e. Popliteal angle less than 90 degrees
ANS: A, B, E
A term newborn will have a posture that is fully flexed (arms and legs) and a brisk arm recoil.
The popliteal angle in a term infant is less than 90 degrees. The square window should show
no angle, the hand should lie flat on the ventral surface of the arm in the term newborn. In a
term newborn, the elbow should not cross the midline during assessment of the scarf sign.
DIF: Cognitive Level: Analyze
REF: p. 193
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
SHORT ANSWER
1. A nurse is performing a 1-minute Apgar on a newborn. The nurse assesses that the newborn
has a heart rate over 100, a good strong cry, some flexion of extremities, sneezes, and has a
pink body with blue extremities. The nurse records what number as the Apgar? Record your
answer in a whole number.
ANS:
8
Sign
Heart rate
Respiratory
effort
Muscle tone
Reflex
irritability
Color
0
Absent
Absent
Limp
No response
Blue, pale
1
Slow, <100 beats/min
Irregular, slow, weak cry
2
>100 beats/min
Good, strong cry
Some flexion of
extremities
Grimace
Well flexed
Body pink, extremities
blue
Completely pink
Cry, sneeze
The newborn gets 2 for heart rate, 2 for respiratory effort, 1 for muscle tone, 2 for reflex
irritability and 1 for color = 8
DIF: Cognitive Level: Apply
REF: p. 193
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
2.A nurse is preparing to administer a prescribed phytonadione (vitamin K) injection 0.5 mg
intramuscularly to a newborn. The phytonadione (vitamin K) ampule is labeled 1 mg equals
0.5 ml. How many milliliters will the nurse administer? Record your answer using two
decimal places.
ANS:
0.25
Formula:
Desired
Available ´ Volume =
0.5 mg
1 mg ´ 0.5 mL = 0.25 mL
DIF: Cognitive Level: Apply
REF: p. 211
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 08: Health Problems of Newborns
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which is defined as a vaguely outlined area of edematous tissue situated over the portion of
the scalp that presents in a vertex delivery?
Caput succedaneum
Hydrocephalus
Cephalhematoma
Subdural hematoma
a.
b.
c.
d.
ANS: A
A vaguely outlined area of edematous tissue situated over the portion of the scalp that
presents in a vertex delivery is the definition of a caput succedaneum. The swelling consists
of serum and/or blood accumulated in the tissues above the bone, and it may extend beyond
the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of
cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the
ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply
demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A
subdural hematoma is located between the dura and the cerebrum. It would not be visible on
the scalp.
DIF: Cognitive Level: Remember
REF: p. 229
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which finding on a newborn assessment should the nurse recognize as suggestive of a
clavicle fracture?
a. Negative scarf sign
b. Asymmetric Moro reflex
c. Swelling of fingers on affected side
d. Paralysis of affected extremity and muscles
ANS: B
A newborn with a broken clavicle may have no symptoms. The Moro reflex, which results in
sudden extension and abduction of the extremities followed by flexion and adduction of the
extremities, will most likely be asymmetric. The scarf sign that is used to determine
gestational age should not be performed if a broken clavicle is suspected. Swelling of fingers
on affected side and paralysis of affected extremity and muscles are not indicative of a
fractured clavicle.
DIF: Cognitive Level: Analyze
REF: p. 231
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The parents of a newborn ask the nurse what caused the baby’s facial nerve paralysis. What
knowledge should the nurse’s response be based on?
a. Genetic defect
b. Birth injury
c. Spinal cord injury
d. Inborn error of metabolism
ANS: B
Pressure on the facial nerve during delivery may result in injury to cranial nerve VII, which
can occur with birth injury. A genetic defect, spinal cord injury, or inborn error of metabolism
would not cause facial paralysis.
DIF: Cognitive Level: Understand
REF: p. 229
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A mother is upset because her newborn has erythema toxicum neonatorum. What information
should the nurse base the response to the mother?
Easily treated
Benign and transient
Usually not contagious
Usually not disfiguring
a.
b.
c.
d.
ANS: B
Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of
unknown cause that usually appears within the first 2 days of life. The rash usually lasts
about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not
contagious. Successive crops of lesions heal without pigmentation.
DIF: Cognitive Level: Apply
REF: p. 233
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. What is oral candidiasis (thrush) in the newborn?
a. Bacterial infection that is life threatening in the neonatal period
b. Bacterial infection of mucous membranes that responds readily to treatment
c. Yeastlike fungal infection of mucous membranes that is relatively common
d. Benign disorder that is transmitted from mother to newborn during the birth
process only
ANS: C
Oral candidiasis, characterized by white adherent patches on the tongue, palate, and inner
aspects of the cheeks, is not uncommon in newborns. Candida albicans is the usual causative
organism. Oral candidiasis is usually a benign disorder in the newborn, often confined to the
oral and diaper regions. It is caused by a yeastlike organism and is treated with good hygiene,
application of a fungicide, and correction of any underlying disorder. Thrush can be
transmitted in several ways, including by maternal transmission during delivery; person-toperson transmission; and contaminated bottles, hands, or other objects.
DIF: Cognitive Level: Understand
REF: p. 233
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. What does nursing care of the newborn with oral candidiasis (thrush) include?
a. Avoiding use of pacifier
b. Removing characteristic white patches with a soft cloth
c. Continuing medication for a prescribed number of days
d. Applying medication to oral mucosa, being careful that none is ingested
ANS: C
The medication must be continued for the prescribed number of days. To prevent relapse,
therapy should continue for at least 2 days after the lesions disappear. Pacifiers can be used.
The pacifier should be replaced with a new one or boiled for 20 minutes once daily. One of
the characteristics of thrush is that the white patches cannot be removed. The medication is
applied to the oral mucosa and then swallowed to treat Candida organisms in the
gastrointestinal tract.
DIF: Cognitive Level: Apply
REF: p. 233
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
7. Which is a bright red, rubbery nodule with a rough surface and a well-defined margin that
may be present at birth?
a. Port-wine stain
b. Juvenile melanoma
c. Cavernous hemangioma
d. Strawberry hemangioma
ANS: D
Strawberry hemangiomas or capillary hemangiomas are benign cutaneous tumors that involve
capillaries only. They are bright red, rubbery nodules with rough surfaces and well-defined
margin. They may or may not be apparent at birth but enlarge during the first year of life and
tend to resolve spontaneously by age 2 to 3 years. Port-wine stain is a vascular stain that is a
permanent lesion and is present at birth. Initially it is a pink, red, or, rarely, purple stain of the
skin that is flat at birth and thickens, darkens, and proportionately enlarges as the child grows.
Melanoma is not differentiated into juvenile and adult forms. A cavernous hemangioma
involves deeper vessels in the dermis and has a bluish red color and poorly defined margins.
DIF: Cognitive Level: Understand
REF: p. 235
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment
will be. What information does the nurse need to include in the response?
a. Excision of the lesion will be necessary.
b. Injections of prednisone into the lesion will reduce it.
c. No treatment is usually necessary because of the high rate of spontaneous
involution.
d. Pulsed dye laser treatments will be necessary immediately to prevent permanent
disability.
ANS: C
There is a high rate of spontaneous resolution, so treatment is usually not indicated for
hemangiomas. Surgical removal would not be indicated. If steroids are indicated, then
systemic prednisone is administered for 2 to 3 weeks. The pulse dye laser is used in the
uncommon situation of potential visual or respiratory impairment.
DIF: Cognitive Level: Apply
REF: p. 235
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Which term refers to a newborn born before completion of week 37 of gestation, regardless
of birth weight?
Postterm
Preterm
Low birth weight
Small for gestational age
a.
b.
c.
d.
ANS: B
A preterm newborn is any child born before 37 weeks of gestation, regardless of birth weight.
A postterm or postmature newborn is any child born after 42 weeks of gestational age,
regardless of birth weight. A low birth weight newborn is a child whose birth weight is less
than 2500 g, regardless of gestational age. A small-for-gestational-age (or small-for-date)
newborn is any child whose rate of intrauterine growth was slowed and whose birth weight
falls below the 10th percentile on intrauterine growth curves.
DIF: Cognitive Level: Remember
REF: p. 235
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Which refers to a newborn whose rate of intrauterine growth was slowed and whose birth
weight falls below the 10th percentile on intrauterine growth charts?
a. Postterm
b. Postmature
c. Low birth weight
d. Small for gestational age
ANS: D
A small-for-gestational-age (or small-for-date) newborn is any child whose rate of
intrauterine growth was slowed and whose birth weight falls below the 10th percentile on
intrauterine growth curves. A postterm or postmature newborn is any child born after 42
weeks of gestational age, regardless of birth weight. A low birth weight newborn is a child
whose birth weight is less than 2500 g, regardless of gestational age.
DIF: Cognitive Level: Remember
REF: p. 236
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. The nurse is caring for a very low birth weight (VLBW) newborn with a peripheral
intravenous infusion. Which statement describes nursing considerations regarding
infiltration?
a. Infiltration occurs infrequently because VLBW newborns are inactive.
b. Continuous infusion pumps stop automatically when infiltration occurs.
c. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
d. Infusion site should be checked for infiltration at least once per 8-hour shift.
ANS: C
Hypertonic fluids can damage cells if the fluid leaks from the vein. Careful monitoring is
required to prevent severe tissue damage. Infiltrations occur for many reasons, not only
activity. The vein, catheter, and fluid used all contribute to the possibility of infiltration. The
continuous infusion pump may alarm when the pressure increases, but this does not alert the
nurse to all infiltrations. Infusion rates and sites should be checked hourly to prevent tissue
damage from extravasations, fluid overload, and dehydration.
DIF: Cognitive Level: Understand
REF: p. 236
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
12. The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer.
The nurse notes blanching of the feet. Which is the most appropriate nursing action?
a. Elevate feet 15 degrees.
b. Place socks on newborn.
c. Wrap feet loosely in prewarmed blanket.
d. Report findings immediately to the practitioner.
ANS: D
Blanching of the feet, in a newborn with an umbilical catheter, is an indication of vasospasm.
Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair
circulation. It is an emergency situation and must be reported immediately.
DIF: Cognitive Level: Apply
REF: p. 239
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
13. The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse
should explain that breastfeeding can be initiated when her newborn:
a. achieves a weight of at least 3 pounds.
b. indicates an interest in breastfeeding.
c. does not require supplemental oxygen.
d. has adequate sucking and swallowing reflexes.
ANS: D
Research supports that human milk is the best source of nutrition for term and preterm
newborns. Preterm newborns should be breastfed as soon as they have adequate sucking and
swallowing reflexes and no other complications such as respiratory complications or
concurrent illnesses. Weight is not an issue. Interest in breastfeeding can be evaluated by
having nonnutritive sucking at the breast during skin-to-skin kangaroo care so the mother and
child may become accustomed to each other. Supplemental oxygen can be provided during
breastfeeding by using a nasal cannula.
DIF: Cognitive Level: Analyze
REF: p. 241
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. Which is the most appropriate nursing action when intermittently gavage-feeding a preterm
newborn?
Allow formula to flow by gravity.
Insert tube through nares rather than mouth.
Avoid letting newborn suck on tube.
Apply steady pressure to syringe to deliver formula to stomach in a timely manner.
a.
b.
c.
d.
ANS: A
The formula is allowed to flow by gravity. The length of time to complete the feeding will
vary. Preferably, the tube is inserted through the mouth. Newborns are obligatory nose
breathers, and the presence of the tube in the nose irritates the nasal mucosa. Passage of the
tube through the mouth allows the nurse to observe and evaluate the sucking response. The
feeding should not be done under pressure. This procedure is not used as a timesaver for the
nurse.
DIF: Cognitive Level: Apply
REF: p. 242
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
15. A healthy, stable, preterm newborn will soon be discharged. The nurse should recommend
which position for sleep?
a. Prone
b. Supine
c. Side lying
d. Position of comfort
ANS: B
The American Academy of Pediatrics recommends that healthy newborns be placed to sleep
in a supine position. Other positions are associated with sudden infant death syndrome. The
prone position can be used for supervised play.
DIF: Cognitive Level: Apply
REF: p. 252
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. Which intervention should the nurse implement to maintain the skin integrity of the preterm
newborn?
a. Cleanse skin with a gentle alkaline-based soap and water.
b. Cleanse skin with a neutral pH solution only when necessary.
c. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene
solution.
d. Avoid cleaning skin.
ANS: B
The preterm newborn should be given baths no more than two or three times per week with a
neutral pH solution. The eyes, oral and diaper areas, and pressure points should be cleansed
daily. Alkaline-based soaps might destroy the acid mantle of the skin. They should not be
used. The increased permeability of the skin facilitates absorption of the chemical
ingredients. The newborn’s skin must be cleaned to remove stool and urine, which are
irritating to the skin.
DIF: Cognitive Level: Apply
REF: p. 245
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
17. Which is an important nursing action related to the use of tape and/or adhesives on preterm
newborns?
a. Avoid using tape and adhesives until skin is more mature.
b. Use solvents to remove tape and adhesives instead of pulling on skin.
c. Remove adhesives with warm water or mineral oil.
d. Use scissors carefully to remove tape instead of pulling tape off.
ANS: C
Warm water, mineral oil, or petrolatum can be used to facilitate the removal of adhesive. In
the preterm newborn, often it is impossible to avoid using adhesives and tape. The smallest
amount of adhesive necessary should be used. Solvents should be avoided because they tend
to dry and burn the delicate skin. Scissors should not be used to remove dressings or tape
from the extremities of very small and immature newborns because it is easy to snip off tiny
extremities or nick loosely attached skin.
DIF: Cognitive Level: Analyze
REF: p. 245
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
18. The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While
taking vital signs and changing the newborn’s diaper, the nurse observes the newborn’s color
is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and
heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations
of:
a. stress.
b. subtle seizures.
c. preterm behavior.
d. onset of respiratory distress.
ANS: A
Color pink but slightly mottled, arms and legs limp and extended, hiccups, respiratory pauses
and gasping, and an irregular, rapid heart rate are signs of stress or fatigue in a newborn.
Neonatal seizures usually have some type of repetitive movement from twitching to rhythmic
jerking movements. The behavior of a preterm newborn may be inactive and listless.
Respiratory distress is exhibited by retractions and nasal flaring.
DIF: Cognitive Level: Understand
REF: p. 247
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
19. When is the best time for the neonatal intensive care unit (NICU) nurse to initiate an
individualized stimulation program for the preterm newborn?
As soon as possible after newborn is born
As soon as parent is available to provide stimulation
When newborn is over 38 weeks of gestation
When developmental organization and stability are sufficient
a.
b.
c.
d.
ANS: D
Newborn stimulation is essential for growth and development. The appropriate time for the
introduction of an individualized program is when developmental organization and stability
are achieved at approximately 34 and 36 weeks of gestation. The newborn needs to be
developmentally ready for a stimulation program. The newborn must be assessed to
determine the readiness and appropriateness of the stimulation program. The program should
be designed and implemented by the nursing staff. The family can be involved, as the nurses
help teach the parents to be responsive to the child’s cues, but the stimulation should not
depend on the family’s availability. An individualized stimulation program should be started
when the child is developmentally ready.
DIF: Cognitive Level: Analyze
REF: p. 244
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of
the newborn express apprehension and worry that the newborn may still be in danger. How
should the nurse interpret these statements?
a. Normal
b. A reason to postpone discharge
c. Suggestive of maladaptation
d. Suggestive of inadequate bonding
ANS: A
Parents become apprehensive and excited as the time for discharge approaches. They have
many concerns and insecurities regarding the care of their newborn. A major concern is that
they may be unable to recognize signs of illness or distress in their newborn. Preparation for
discharge should begin early and include helping the parent acquire the skills necessary for
care. Apprehension and worry are normal adaptive responses. The NICU nurses should
facilitate discharge by involving parents in care as soon as possible.
DIF: Cognitive Level: Understand
REF: p. 248
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
21. The nurse is planning care for a family expecting their newborn to die. The nurse’s
interventions should be based on which statement?
Tangible remembrances of the newborn (e.g., lock of hair, picture) prolong grief.
Photographs of newborns should not be taken after the death has occurred.
Funerals are not recommended because mother is still recovering from childbirth.
Parents should be encouraged to name their newborn if they have not done so
already.
a.
b.
c.
d.
ANS: D
Naming the deceased newborn is an important step in the grieving process. It gives the
parents a tangible person for whom to grieve, which is a key component of the grieving
process. Tangible remembrances and photographs can make the newborn seem more real to
the parents. Many NICUs will make bereavement memory packets, which may include a lock
of hair, handprint, footprints, bedside name card, and other individualized objects. Families
need to be informed of their options. The ritual of a funeral provides an opportunity for the
parents to be supported by relatives and friends.
DIF: Cognitive Level: Analyze
REF: p. 248
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
22. The nurse has been caring for a newborn who just died. The parents are present but say they
are “afraid” to hold the dead newborn. Which is the most appropriate nursing intervention?
Tell them there is nothing to fear.
Insist that they hold newborn “one last time.”
Respect their wishes and release body to morgue.
Keep newborn’s body available for a few hours in case they change their minds.
a.
b.
c.
d.
ANS: D
When the parents are hesitant about holding and touching their newborn, the nurse should
keep the newborn’s body for a few hours. Many parents change their minds after the initial
shock of the newborn’s death. This will provide the parents time to see and hold their
newborn if they desire. Stating that there is nothing to fear minimizes the parents’ feelings.
The nurse should allow the family to parent their child as they wish in death, as in life. Many
parents change their minds; if possible, the nurse should wrap the newborn in blankets and
keep the newborn’s body on the unit for a few hours.
DIF: Cognitive Level: Apply
REF: p. 236
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
23. The nurse is planning care for a low birth weight newborn. Which is an appropriate nursing
intervention to promote adequate oxygenation?
a. Place in Trendelenburg position periodically.
b. Suction at least every 2 to 3 hours.
c. Maintain neutral thermal environment.
d. Hyperextend neck with nose pointing to ceiling.
ANS: C
A neutral thermal environment is one that permits the newborn to maintain a normal core
temperature with minimal oxygen consumption and caloric expenditure. The Trendelenburg
position should be avoided. This position can contribute to increased intracranial pressure
(ICP) and reduced lung capacity from gravity pushing organs against diaphragm. Suctioning
should be done only as necessary. Routine suctioning may cause bronchospasm, bradycardia
due to vagal nerve stimulation, hypoxia, and increased ICP. Neck hyperextension is avoided
because it reduces diameter of trachea.
DIF: Cognitive Level: Apply
REF: p. 239
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
24. A preterm newborn has been receiving orogastric feedings of breast milk. The nurse initiates
nipple feedings, but the newborn tires easily and has weak sucking and swallowing reflexes.
What is the most appropriate nursing intervention?
a. Encourage mother to breastfeed.
b. Try nipple-feeding preterm newborn formula.
c. Resume orogastric feedings of breast milk.
d. Resume orogastric feedings of formula.
ANS: C
If a preterm newborn tires easily or has weak sucking when nipple feedings are initiated, the
nurse should resume orogastric feedings with the milk of mother’s choice. When nipple
feeding is unsuccessful, it is unlikely that the newborn will be able to breastfeed. Breast milk
should be continued as long as the mother desires.
DIF: Cognitive Level: Apply
REF: p. 241
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
25. The parents of a newborn who has just died decide they want to hold their deceased infant.
What is the most appropriate nursing intervention?
Explain gently that this is no longer possible.
Encourage parents to accept the loss of their newborn.
Offer to take a photograph of their newborn because they cannot hold newborn.
Get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can
hold their deceased infant.
a.
b.
c.
d.
ANS: D
The parents should be allowed to hold their newborn in the hospital setting. The newborn’s
body should be retrieved and rewarmed in a radiant warmer. The nurse should provide a
private place where the parents can hold their child for a final time. A photograph is an
excellent idea, but it does not replace the parents’ need to hold the child.
DIF: Cognitive Level: Apply
REF: p. 250
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
26. Which statement best describes the clinical manifestations of the preterm newborn?
a. Head is proportionately small in relation to the body.
b. Sucking reflex is absent, weak, or ineffectual.
c. Thermostability is well established.
d. Extremities remain in attitude of flexion.
ANS: B
Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. The
preterm newborn’s head is proportionately larger than the body. Thermoregulation is poorly
developed, and the preterm newborn needs a neutral thermal environment to be provided. The
preterm newborn may be listless and inactive compared with the overall attitude of flexion
and activity of a full-term newborn.
DIF: Cognitive Level: Understand
REF: p. 250
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
27. Physiologic jaundice in a newborn can be caused by:
a. fetal-maternal blood incompatibility.
b. destruction of red blood cells as a result of antibody reaction.
c. liver’s inability to bind bilirubin adequately for excretion.
d. immature kidneys’ inability to hydrolyze and excrete bilirubin.
ANS: C
Physiologic jaundice is caused by the immature hepatic function of the newborn’s liver
coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the
destroyed red blood cells cannot be excreted from the body. The fetal-maternal blood
incompatibility and the associated red cell destruction by antibodies are the causes of
hemolytic disease of the newborn. The kidneys are not involved in the excretion of bilirubin.
DIF: Cognitive Level: Understand
REF: p. 255
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
28. When should the nurse expect breastfeeding-associated jaundice to first appear in a normal
newborn?
a. 0 to 12 hours
b. 12 to 24 hours
c. 2 to 4 days
d. 4 to 5 days
ANS: C
Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased
caloric and fluid intake by the newborn before the mother’s milk is well established. Fasting
is associated with decreased hepatic clearance of bilirubin; 0 to 24 hours is too soon. Jaundice
within the first 24 hours is associated with hemolytic disease of the newborn; 4 to 5 days is
too late. Jaundice at this time may be due to breast milk jaundice.
DIF: Cognitive Level: Understand
REF: p. 255
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
29. The newborn with severe jaundice is at risk for developing:
a. encephalopathy.
b. bullous impetigo.
c. respiratory distress.
d. blood incompatibility.
ANS: A
Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. A
newborn with severe jaundice is at risk for developing kernicterus or bilirubin
encephalopathy. Encephalopathy is a highly infectious bacterial infection of the skin. It has
no relation to severe jaundice and is the most likely complication of severe jaundice. A blood
incompatibility may be the causative factor for the severe jaundice.
DIF: Cognitive Level: Understand
REF: p. 259
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
30. What is an early clinical manifestation of bilirubin encephalopathy in the newborn?
a. Cognitive impairment
b. Absence of stooling
c. Lethargy or irritability
d. Increased or decreased temperature
ANS: C
Clinical manifestations of bilirubin encephalopathy are those of nervous system depression or
excitation. Prodromal symptoms consist of decreased activity, lethargy, irritability, hypotonia,
and seizures. Newborns who survive may have evidence of cognitive impairment. Absence of
stooling and increased/decreased temperature are not manifestations of bilirubin
encephalopathy.
DIF: Cognitive Level: Understand
REF: p. 259
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
31. A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess
for jaundice in this newborn?
Buttocks
Tip of nose and sclera
Sclera, conjunctiva, and oral mucosa
Palms of hands and soles of feet
a.
b.
c.
d.
ANS: C
Assessing for jaundice is part of the routine physical assessment in newborns. In darkskinned newborns, the sclera, conjunctiva, and oral mucosa are the best place to observe
jaundice because of the lack of skin pigmentation in these areas. The skin pigmentation in the
buttocks, tip of nose and sclera, and palms of hands and soles of feet can mask the
appearance of jaundice.
DIF: Cognitive Level: Apply
REF: p. 258
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
32. A blood sample for measurement of bilirubin is required from a newborn receiving
phototherapy. In what environment should this blood sample be drawn?
While phototherapy lights are turned off
While newborn remains under phototherapy lights
When newborn is covered with a blanket
When newborn has been off phototherapy for 30 to 60 minutes
a.
b.
c.
d.
ANS: A
When blood is drawn, phototherapy lights are turned off, and the blood is transported in a
covered tube to avoid a false reading as a result of bilirubin destruction in the test tube. The
lights will cause a degradation of the bilirubin in the sample, resulting in a falsely lowered
result. The newborn does not need to be covered with a blanket. The phototherapy lights must
be off. There is no reason to delay obtaining the blood sample. It can be drawn as soon as the
lights are turned off.
DIF: Cognitive Level: Apply
REF: p. 262
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
33. The nurse is preparing a parent of a newborn for home phototherapy. Which statement made
by the parent would indicate a need for further teaching?
“I should change the baby’s position many times during the day.”
“I can dress the baby in lightweight clothing while under phototherapy.”
“I should be sure that the baby’s eyelids are closed before applying patches.”
“I can take the patches off the baby during feedings and other caregiving
activities.”
a.
b.
c.
d.
ANS: B
The baby should be placed nude under the lights. The newborn should be repositioned
frequently to expose all body surfaces to the lights. The newborn’s eyelids must be closed
before the patches are applied because the corneas may become excoriated if in contact with
the dressing. The eye patches should be removed during feedings and other caregiving
activities so the newborn can have visual and sensory stimulation.
DIF: Cognitive Level: Analyze
REF: p. 262
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
34. The nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy.
Which is an appropriate nursing intervention for this newborn?
a. Apply lotion as prescribed to moisturize skin.
b. Maintain nothing-by-mouth (NPO) status to prevent nausea and vomiting.
c. Monitor temperature to prevent hypothermia or hyperthermia.
d. Keep eye patches on for at least 8 to 12 of every 24 hours.
ANS: C
Newborns who are receiving phototherapy are at risk for thermoregulation issues. The nurse
must monitor the newborn’s temperature closely to rapidly detect either hypothermia or
hyperthermia. Lotions are not used. They may predispose the newborn to increased tanning
or “frying” effect. Newborns receiving phototherapy require additional fluid to compensate
for increased fluid losses caused by the lights. The eye patches must be in place whenever the
child is under the phototherapy lights.
DIF: Cognitive Level: Apply
REF: p. 262
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
35. Hemolytic disease is suspected in a mother’s second newborn. Which factor is important in
understanding how this could develop?
a. The mother’s first child was Rh positive.
b. The mother is Rh positive.
c. Both parents have type O blood.
d. RhIG (RhoGAM) was given to the mother during her first pregnancy.
ANS: A
Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell
(RBC) destruction. The major causes of this are Rh and maternal-fetal ABO incompatibility.
If an Rh-negative mother has previously been exposed to Rh-positive blood through
pregnancy or blood transfusion, antibodies to this blood group antigen may develop so that
she is isoimmunized. With further exposure to Rh, the maternal antibodies will agglutinate
with the red cells of the fetus who has the antigen and destroy the cells. Hemolytic disease is
also caused by ABO incompatibilities. Blood type is the important consideration. If both
parents are type O blood, ABO incompatibility would not be a possibility. The mother should
have received Rho(D) immune globulin to prevent antibody development after the first
pregnancy.
DIF: Cognitive Level: Analyze
REF: p. 264
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
36. When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
a. At birth
b. During first 24 hours after birth
c. 24 to 48 hours after birth
d. 48 to 72 hours after birth
ANS: B
In hemolytic disease of the newborn, jaundice is usually evident within the first 24 hours of
life. Newborns with hemolytic disease are usually not jaundiced at birth, although some
degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most
severe form, hydrops fetalis, is present; 24 to 72 hours is too late for hemolytic disease of the
newborn. Jaundice at these ages is most likely due to physiologic or early-onset breastfeeding
jaundice.
DIF: Cognitive Level: Understand
REF: p. 264
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
37. To whom is RhIG (RhoGAM) administered to prevent Rh isoimmunization?
a. Rh-negative women who deliver an Rh-positive newborn
b. Rh-positive women who deliver an Rh-negative newborn
c. Rh-negative newborns whose mothers are Rh positive
d. Rh-positive fathers before conception of second newborn when first newborn was
Rh positive
ANS: A
RhIG human gamma globulin concentrate of anti-D is administered to all unsensitized Rhnegative women after delivery or abortion of an Rh-positive newborn or fetus. Administering
RhIG to an individual who is Rh positive will result in agglutination of red cells and
hemolysis. It will not alter the person’s genetic makeup. The anti-D antibody contained in
RhIG will have no effect on Rh-negative newborns because the D antibody is not present.
DIF: Cognitive Level: Apply
REF: p. 265
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
38. The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease.
Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should
the nurse’s first action be?
a. Notify practitioner.
b. Stop the transfusion.
c. Administer calcium gluconate.
d. Monitor vital signs electronically.
ANS: B
When signs of cardiac or respiratory problems occur, the procedure is stopped, and the
newborn’s cardiorespiratory status is allowed to stabilize. The practitioner is usually
performing the exchange transfusion with the nurse’s assistance. The procedure must be
stopped so the newborn can stabilize. Respiratory distress and tachycardia are signs of
cardiorespiratory problems, not hypocalcemia. Calcium gluconate is not indicated. The vital
signs should be monitored electronically throughout the entire procedure.
DIF: Cognitive Level: Apply
REF: p. 265
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
39. Which is the primary treatment for hypoglycemia in newborns with feeding intolerance?
a. Oral glucose feedings
b. Intravenous (IV) infusion of glucose
c. Short-term insulin therapy
d. Feedings (formula or breast milk) at least every 2 hours
ANS: B
IV infusions of glucose are indicated when the glucose level is very low and when feedings
are not tolerated. Early feedings in the normoglycemic newborn are preventive. When the
newborn is unable to tolerate feedings or the blood glucose level has become extremely low,
then IV infusions are indicated. Insulin administration will further depress the blood glucose
level. Feedings can be preventive. The child may not be able to tolerate this frequency.
DIF: Cognitive Level: Apply
REF: p. 241
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
40. Which is the most appropriate nursing intervention for the newborn who is jittery and
twitching and has a high-pitched cry?
a. Monitor blood pressure closely.
b. Obtain urine sample to detect glycosuria.
c. Obtain serum glucose and serum calcium levels.
d. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
ANS: C
These are signs and symptoms of hypocalcemia and hypoglycemia. A blood test is useful to
determine the treatment. Laboratory analysis for calcium and blood glucose should be the
priority intervention. Monitoring vital signs is important, but recognition of the possible
hypocalcemia and hypoglycemia is imperative. A finding of glycosuria would not facilitate
the diagnosis of hypoglycemia. A determination must be made between the hypocalcemia and
hypoglycemia before treatment can be initiated.
DIF: Cognitive Level: Apply
REF: p. 283
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
41. The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of
hypocalcemia. Which intervention is the most appropriate during the acute phase?
Allow newborn to sleep with pacifier to decrease stimuli.
Keep newborn awake to monitor central nervous system changes.
Encourage parents to hold and feed newborn to facilitate attachment during illness.
Awaken newborn periodically to assess level of consciousness.
a.
b.
c.
d.
ANS: A
For newborns with hypocalcemia, the nurse should manipulate the environment to reduce
stimuli that might precipitate a seizure or tremors. A quiet, nonstimulating environment
should be maintained for the newborn until calcium levels are normalized. Care should be
provided without sudden jarring. Parents can be involved in observations and care when the
child is awake.
DIF: Cognitive Level: Apply
REF: p. 284
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
42. Which is the central factor responsible for respiratory distress syndrome?
a. Deficient surfactant production
b. Overproduction of surfactant
c. Overdeveloped alveoli
d. Absence of alveoli
ANS: A
The successful adaptation to extrauterine breathing requires numerous factors, which most
term newborns successfully accomplish. Preterm newborns with respiratory distress are not
able to adjust. The most likely central cause is the abnormal development of the surfactant
system. The deficient production of surfactant results in unequal inflation of alveoli on
inspiration and the collapse of the alveoli on end expiration. The number and state of
development of the alveoli are not a central factors in respiratory distress syndrome. The
instability of the alveoli related to the lack of surfactant is the causative issue.
DIF: Cognitive Level: Remember
REF: p. 267
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
43. A preterm newborn of 36 weeks of gestation is admitted to the NICU. Approximately 2 hours
after birth, the newborn begins having difficulty breathing, with grunting, tachypnea, and
nasal flaring. Which is important for the nurse to recognize?
a. This is a normal finding.
b. This is not significant unless cyanosis is present.
c. Improvement should occur within 24 hours.
d. Further evaluation is needed.
ANS: D
Difficulty breathing, with grunting, tachypnea, and nasal flaring are clinical manifestations of
respiratory distress syndrome and require further evaluation. This is not a normal finding and
requires further evaluation. Cyanosis may be present, but these are significant findings
indicative of respiratory distress without cyanosis. The child’s condition will most likely
worsen for approximately 48 hours without intervention. Improvement may begin at 72
hours.
DIF: Cognitive Level: Analyze
REF: p. 269
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
44. The nurse is caring for a preterm newborn who requires mechanical ventilation for the
treatment of respiratory distress syndrome. What is the preterm newborn at increased risk of
due to the mechanical ventilation?
a. Alveolar rupture
b. Meconium aspiration
c. Transient tachypnea
d. Retractions and nasal flaring
ANS: A
Positive pressure introduced by mechanical apparatus has created an increase in the incidence
of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia.
Meconium aspiration is not associated with mechanical ventilation. Tachypnea may be an
indication of a pneumothorax, but it would not be transient. Retractions and nasal flaring are
indications of the use of accessory muscles when the newborn cannot obtain sufficient
oxygen. The use of mechanical ventilation bypasses the newborn’s need to use these muscles.
DIF: Cognitive Level: Understand
REF: p. 273
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
45. The nurse is caring for a newborn with respiratory distress syndrome. The newborn has an
endotracheal tube. Which statement describes nursing considerations related to suctioning?
Suctioning should not be carried out routinely.
Newborn should be in Trendelenburg position for suctioning.
Routine suctioning, usually every 15 minutes, is necessary.
Frequent suctioning is necessary to maintain patency of bronchi.
a.
b.
c.
d.
ANS: A
Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia,
and increased ICP. It should never be carried out routinely. The Trendelenburg position
should be avoided. This position can contribute to increased ICP and reduced lung capacity
from gravity pushing organs against diaphragm. Routine suctioning is avoided because of the
potential complications of bronchospasm, bradycardia, hypoxia, and increased ICP.
DIF: Cognitive Level: Apply
REF: p. 267
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
46. A preterm newborn requires oxygen and mechanical ventilation. Which complications should
the nurse assess for?
Bronchopulmonary dysplasia, pneumothorax
Anemia, necrotizing enterocolitis
Cerebral palsy, persistent patent ductus
Congestive heart failure, cerebral edema
a.
b.
c.
d.
ANS: A
Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by
mechanical ventilation creates an increase in the number of ruptured alveoli and subsequent
pneumothorax and bronchopulmonary dysplasia. Anemia, necrotizing enterocolitis, cerebral
palsy, persistent patent ductus, congestive heart failure, and cerebral edema are complications
not primarily due to oxygen therapy and mechanical ventilation.
DIF: Cognitive Level: Analyze
REF: p. 271
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
47. What causes meconium aspiration syndrome?
a. Hypoglycemia
b. Carbon dioxide retention
c. Bowel obstruction with meconium
d. Aspiration of meconium in utero or at birth
ANS: D
Meconium aspiration syndrome is caused by the aspiration of amniotic fluid containing
meconium into the fetal or newborn trachea in utero or at first breath. Hypoglycemia and
carbon dioxide retention are not related to meconium aspiration. Bowel obstruction with
meconium may be an indication of cystic fibrosis or Hirschsprung disease, not meconium
aspiration.
DIF: Cognitive Level: Understand
REF: p. 272
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
48. Which is the most common cause of anemia in preterm newborns?
a. Frequent blood sampling
b. Respiratory distress syndrome
c. Meconium aspiration syndrome
d. Persistent pulmonary hypertension
ANS: A
The most common cause of anemia in preterm newborns is frequent blood-sample
withdrawal and inadequate erythropoiesis in acutely ill newborns. Microsamples should be
used for blood tests, and the amount of blood drawn should be monitored. Respiratory
distress syndrome, meconium aspiration syndrome, and persistent pulmonary hypertension
are not causes of anemia. They may require frequent blood sampling, which will contribute to
the problem of decreased erythropoiesis and anemia.
DIF: Cognitive Level: Understand
REF: p. 277
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
49. A newborn is diagnosed with retinopathy of prematurity. What should the nurse know about
this diagnosis?
Blindness cannot be prevented.
No treatment is currently available.
Cryotherapy and laser therapy are effective treatments.
Long-term administration of oxygen will be necessary.
a.
b.
c.
d.
ANS: C
Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular
proliferation process that causes the retinal damage. Blindness can be prevented with early
recognition and treatment. Cryotherapy and laser therapy can be used to stop the process.
Surgical intervention can be used to repair a detached retina if necessary. Long-term
administration of oxygen is one of the causes. Oxygen should be used judiciously.
DIF: Cognitive Level: Understand
REF: p. 272
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
50. Several types of seizures can occur in the newborn. Which is characteristic of clonic seizures?
a. Apnea
b. Tremors
c. Rhythmic jerking movements
d. Extensions of all four limbs
ANS: C
Clonic seizures are characterized by slow rhythmic jerking movements that occur
approximately 1 to 3 per second. Apnea is a common manifestation of subtle seizures.
Tremors are not characteristic of seizure activity. They may be indicative of hypoglycemia or
hypocalcemia. A clonic seizure would have extension and contraction of the extremities, not
just extension.
DIF: Cognitive Level: Understand
REF: p. 277
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
51. Newborns are highly susceptible to infection as a result of:
a. excessive levels of immunoglobulin A (IgA) and immunoglobulin M (IgM).
b. diminished nonspecific and specific immunity.
c. increased humoral immunity.
d. overwhelming anti-inflammatory response.
ANS: B
Newborns have diminished inflammatory (nonspecific) and humoral (specific) immunity.
They are unable to mount a local inflammatory reaction at the portal of entry to signal
infection, and the resulting symptoms are vague and nonspecific, delaying diagnosis and
treatment. Newborns have diminished or absent IgA and IgM. Humoral and antiinflammatory immune responses are diminished in newborns.
DIF: Cognitive Level: Understand
REF: p. 282
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
52. Which is most descriptive of the clinical manifestations observed in neonatal sepsis?
a. Seizures and sunken fontanels
b. Sudden hyperthermia and profuse sweating
c. Decreased urinary output and frequent stools
d. Nonspecific physical signs with hypothermia
ANS: D
The clinical manifestations of neonatal sepsis are usually characterized by the newborn
generally “not doing well.” Poor temperature control, usually with hypothermia, lethargy,
poor feeding, pallor, cyanosis or mottling, and jaundice, may be evident. Seizures and sunken
fontanels are not manifestations of the sepsis. Severe neurologic sequelae may occur in low
birth weight children with sepsis. Hyperthermia is rare in neonatal sepsis. Urinary output is
not affected by sepsis.
DIF: Cognitive Level: Understand
REF: p. 279
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
53. The nurse is caring for a newborn whose mother is diabetic. Which clinical manifestations
should the nurse expect to see?
Hypoglycemic, large for gestational age
Hyperglycemic, large for gestational age
Hypoglycemic, small for gestational age
Hyperglycemic, small for gestational age
a.
b.
c.
d.
ANS: A
The clinical manifestations of a newborn born to a mother with diabetes include being large
for gestational age, being plump and full-faced, having abundant vernix caseosa, being
listless and lethargic, and having hypoglycemia. These manifestations appear a short time
after birth. The newborn is hypoglycemic from increased fetal production of insulin and large
for gestational age.
DIF: Cognitive Level: Understand
REF: p. 282
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
54. The nurse is caring for a newborn who was born 24 hours ago to a mother who received no
prenatal care. The newborn is a poor feeder but sucks avidly on his hands. Clinical
manifestations also include loose stools, tachycardia, fever, projectile vomiting, sneezing, and
generalized sweating. Which should the nurse suspect?
a. Seizure disorder
b. Narcotic withdrawal
c. Placental insufficiency
d. Meconium aspiration syndrome
ANS: B
Newborns exposed to drugs in utero usually show no untoward effects until 12 to 24 hours
for heroin or much longer for methadone. The newborn usually has nonspecific signs that
may coexist with other conditions such as hypocalcemia and hypoglycemia. In addition, these
newborns may have loose stools, tachycardia, fever, projectile vomiting, sneezing, and
generalized sweating, which is uncommon in newborns. Loose stools, tachycardia, fever,
projectile vomiting, sneezing, and generalized sweating are manifestations not descriptive of
seizure activity. Placental insufficiency usually results in a child who is small for gestational
age. Meconium aspiration syndrome usually has manifestations of respiratory distress.
DIF: Cognitive Level: Apply
REF: p. 278
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
55. Which should the nurse anticipate in the newborn whose mother used cocaine during
pregnancy?
a. Seizures
b. Hyperglycemia
c. Cardiac and respiratory problems
d. Neurobehavioral depression or excitability
ANS: D
The nurse should anticipate neurobehavioral depression or excitability and implement care
directed at the newborn’s manifestations. Few or no neurologic sequelae appear in newborns
born to mothers who use cocaine during pregnancy. The newborn is usually a poor feeder, so
hypoglycemia would be a more likely occurrence. Cardiac and respiratory problems are
usually not evident in these newborns.
DIF: Cognitive Level: Understand
REF: p. 286
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
56. Which is characteristic of newborns whose mothers smoked during pregnancy?
a. Large for gestational age
b. Preterm, but size appropriate for gestational age
c. Growth retardation in weight only
d. Growth retardation in weight, length, and head circumference
ANS: D
Newborns born to mothers who smoke had growth failure in weight, length, and chest
circumference when compared with newborns of mothers who did not smoke. A dose-effect
relation exists. Newborns have significant growth failure, which is related to the number of
cigarettes smoked.
DIF: Cognitive Level: Understand
REF: p. 287
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
57. Which is an important nursing consideration in preventing the complications of congenital
hypothyroidism (CH)?
a. Assess for family history of CH.
b. Assess mother for signs of hypothyroidism.
c. Be certain appropriate screening is done prenatally.
d. Be certain appropriate screening is done on newborn.
ANS: D
Early diagnosis and treatment are essential to prevent the complications of CH. Neonatal
screening is mandatory in all 50 United States and territories and is usually obtained in the
first 24 to 48 hours of birth. A number of different etiologies exist for CH; family history will
identify a small percentage only. The screening can be done postnatally on blood obtained via
heel stick.
DIF: Cognitive Level: Understand
REF: p. 291
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
58. Phenylketonuria (PKU) is a genetic disease that results in the body’s inability to correctly
metabolize:
a. glucose.
b. phenylalanine.
c. phenylketones.
d. thyroxine.
ANS: B
PKU is an inborn error of metabolism caused by a deficiency or absence of the enzyme
needed to metabolize the essential amino acid phenylalanine. Phenylalanine hydroxylase is
missing in PKU. Individuals with this disorder can metabolize glucose. Phenylketones are
metabolites of phenylalanine, excreted in the urine. Thyroxine is one of the principal
hormones secreted by the thyroid gland.
DIF: Cognitive Level: Understand
REF: p. 292
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
59. What is the Guthrie blood test use to diagnose in the newborn?
a. Down syndrome
b. Isoimmunization
c. PKU
d. Congenital hypothyroidism (CH)
ANS: C
The Guthrie blood test is an assay commonly used to diagnosis PKU. The test should be
performed after the newborn has received postnatal feedings. Down syndrome is diagnosed
through chromosomal analysis. Isoimmunization is detected by analysis of blood for
unexpected antibodies. CH is diagnosed by analysis of a filter paper blood spot for thyroxine
(T4).
DIF: Cognitive Level: Remember
REF: p. 292
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
60. The screening test for PKU is most reliable if the blood sample is:
a. from cord blood.
b. taken 14 days after birth.
c. taken before oral feedings are initiated.
d. fresh blood from the heel.
ANS: D
Fresh heel-stick blood is the preferred source for the test. Fresh heel-stick blood, not cord
blood, must be used. The test must be performed soon after birth so that a low-phenylalanine
diet can be instituted if required. The newborn should ingest breast milk or formula before the
test is performed.
DIF: Cognitive Level: Understand
REF: p. 292
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
61. Which is an important nursing consideration in the care of the newborn with PKU?
a. Suggest ways to make formula more palatable.
b. Teach proper administration of phenylalanine hydroxylase.
c. Encourage the breastfeeding mother to adhere to a low-phenylalanine diet.
d. Give reassurance that dietary restrictions are a temporary inconvenience.
ANS: A
To achieve optimal metabolic control, a restricted phenylalanine diet will probably be
required for virtually all individuals with classic PKU throughout life. The nurse and
nutritionist should work with families to make the formula more palatable for the newborn.
Phenylalanine hydroxylase is not effective because it cannot act within the cell where
phenylalanine is metabolized. Partial breastfeeding may be possible, but only with extremely
careful monitoring of the newborn’s blood levels. According to the latest research, lifelong
dietary restriction may be necessary.
DIF: Cognitive Level: Apply
REF: p. 292
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse needs to obtain blood for ongoing assessment of a high-risk newborn’s progress.
Which tests should the nurse monitor? (Select all that apply.)
Blood glucose
Complete blood count (CBC)
Calcium
Serum electrolytes
Neonatal prothrombin time (PTT)
a.
b.
c.
d.
e.
ANS: A, C, D
The most common blood tests done on high-risk newborns are blood glucose, bilirubin,
calcium, hematocrit, serum electrolytes, and blood gases. Hematocrits rather than CBCs are
performed. This will monitor the red cell volume. Neonatal prothrombin time (PTT) is not a
test.
DIF: Cognitive Level: Understand
REF: p. 238
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
2. Which are clinical manifestations of the postterm newborn? (Select all that apply.)
a. Excessive lanugo
b. Increased subcutaneous fat
c. Absence of scalp hair
d. Parchment-like skin
e. Minimal vernix caseosa
f. Long fingernails
ANS: D, E, F
In postterm newborns, the skin is often cracked, parchment-like, and desquamating; there is
little to no vernix caseosa; and fingernails are long. Lanugo is usually absent in postterm
newborns. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance.
Scalp hair is usually abundant.
DIF: Cognitive Level: Understand
REF: p. 255
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are
appropriate? (Select all that apply.)
a. Avoid stimulation.
b. Decrease fluid intake.
c. Expose all the newborn’s skin.
d. Monitor skin temperature closely.
e. Reposition the newborn every 2 hours.
f. Cover the newborn’s eyes with eye shields or patches.
ANS: D, E, F
Several nursing interventions are instituted to protect the newborn during phototherapy.
Temperature is closely monitored to prevent hyperthermia or hypothermia. The newborn is
repositioned every 2 hours to maximize exposure to the phototherapy and to prevent skin
breakdown. The infant’s eyes are shielded by an opaque mask to prevent exposure to the
light. The newborn is clothed in a diaper because a side effect of phototherapy includes loose,
greenish stools. Other side effects include increased metabolic rate; dehydration; electrolyte
disturbances, such as hypocalcemia; and priapism. Infants receiving phototherapy may
require additional fluid volume to compensate for insensible and intestinal fluid loss. The
infant should receive adequate stimulation, which includes feeding and touching.
DIF: Cognitive Level: Apply
REF: p. 258
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment
4. A nurse is planning care for a preterm newborn. Which interventions should the nurse
implement for skin care? (Select all that apply.)
Use cleaning agents with neutral pH.
Rub skin during drying.
Use adhesive remover solvent when removing tape.
Avoid removing adhesives for at least 24 hours.
Consider pectin barriers beneath adhesives.
a.
b.
c.
d.
e.
ANS: A, D, E
The skin care for a preterm newborn should include use of pH-neutral cleanser or soaps no
more than two or three times a week. Adhesives should not be removed for at least 24 hours
after application. Pectin barriers should be used beneath adhesives to protect skin. Avoid
rubbing skin during bathing or drying. Do not use adhesive remover, solvents, or bonding
agents. Adhesive removal can be facilitated using water, mineral oil, or petrolatum.
DIF: Cognitive Level: Apply
REF: p. 259
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
5. A nurse is assessing a preterm newborn for the possibility of necrotizing enterocolitis (NEC).
Which assessment findings should the nurse expect to find if NEC is confirmed? (Select all
that apply.)
a. Minimal gastric residual
b.
c.
d.
e.
Abdominal distention
Apnea
Urinary output at 2 ml/kg/hr
Unstable temperature
ANS: B, C, E
The nurse should observe for indications of early development of NEC by checking the
appearance of the abdomen for distention (measuring abdominal girth, measuring residual
gastric contents before feedings, and listening for bowel sounds) and performing all routine
assessments for high-risk neonates. The preterm newborn may have apnea and unstable
temperature if NEC is developing. The urinary output will be decreased and will be below the
expected 2 ml/kg/hr.
DIF: Cognitive Level: Apply
REF: p. 281
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
6. A nurse is admitting a preterm newborn to the NICU. Which interventions should the nurse
implement to prevent retinopathy? (Select all that apply.)
a. Place on pulse oximetry.
b. Decrease exposure to bright, direct lighting.
c. Place on a cardiac monitor.
d. Cover eyes with an eye shield at night.
e. Use supplemental oxygen only when needed.
ANS: A, B, E
To prevent retinopathy, the nurse should provide preventive care by closely monitoring blood
oxygen levels, responding promptly to saturation alarms, and preventing fluctuations in blood
oxygen levels. Pulse oximetry is recommended to monitor the infant’s oxygenation status
during resuscitation and to prevent excessive use of oxygen in both term and preterm infants.
Decrease exposure to bright, direct lighting; although exposure to bright light has not been
proven to contribute to retinopathy of prematurity, such exposure is undesirable from a
neurobehavioral developmental perspective. Use supplemental oxygen judiciously and
monitor oxygen blood levels carefully; prevent wide fluctuations in oxygen blood levels
(hyperoxia and hypoxia). Placing the newborn on a cardiac monitor will not prevent
retinopathy. Covering the eyes with eye shields is not a preventive measure for retinopathy.
DIF: Cognitive Level: Apply
REF: p. 272
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. A nurse is assessing a preterm newborn. Which assessment findings are consistent with
prematurity? (Select all that apply.)
a. Abundant lanugo over the body
b. Ear cartilage soft and pliable
c. Flexed body posture
d. Deep creases on the sole of the foot
e. Skin is bright pink, smooth, and shiny.
ANS: A, B, E
The preterm newborn has fine lanugo hair that is abundant over the body. The ear cartilage is
soft and pliable, and the soles and palms have minimal creases, resulting in a smooth
appearance. The preterm newborn’s skin is bright pink (often translucent, depending on the
degree of immaturity), smooth, and shiny, with small blood vessels clearly visible underneath
the thin epidermis. In contrast to full-term infants’ overall attitude of flexion and continuous
activity, preterm infants may be inactive and listless. The extremities maintain an attitude of
extension and remain in any position in which they are placed.
DIF: Cognitive Level: Apply
REF: p. 266
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
8. A nurse is reviewing acid-base laboratory data on a newborn admitted to the NICU for
meconium aspiration. Which laboratory values should the nurse report to the physician?
(Select all that apply.)
a. pH: 7.35
b. PCO2: 49
c. HCO3-: 30
d. PaO2: 96
ANS: B, C
Normal values of pH for a newborn are:
Birth: 7.11–7.36
1 day: 7.29–7.45
Child: 7.35–7.45.
Normal values of PCO2 are:
Newborn: 27–40 mm Hg
Infant: 27–41 mm Hg
Girls: 32–45 mm Hg
Boys: 35–48 mm Hg.
Normal values for HCO3- are:
Infant: 21–28 mEq/ml
Thereafter: 22–26 mEq/ml.
The PaO2 is within normal limits for a newborn. Therefore, the nurse should report the PCO2
of 49 and the HCO3- of 30.
DIF: Cognitive Level: Analyze
REF: p. 270
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 09: Health Promotion of the Infant and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is assessing a 12-month-old infant. Which statement best describes the infant’s physical
development a nurse should expect to find?
a.
b.
c.
d.
Anterior fontanel closes by age 6 to 10
months.
Binocularity is well established by age 8
months.
Birth weight doubles by age 5 months and
triples by age 1 year.
Maternal iron stores persist during the first 12
months of life.
ANS: C
Growth is very rapid during the first year of life. The birth weight has approximately doubled by
age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months.
Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by
age 6 months.
DIF: Cognitive Level: Understand
REF: p. 302
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
2. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse
should expect the infant to now weigh approximately how many pounds?
10
15
20
25
a.
b.
c.
d.
ANS: B
Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds at
birth would weigh approximately 15 pounds; 10 pounds is too little. The infant would have gone
from the 50th percentile at birth to below the 5th percentile; 20 to 25 pounds is too much. The infant would have tripled the birth weight at 6 months.
DIF: Cognitive Level: Understand
REF: p. 301
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior
fontanel is closed. How should the nurse interpret this finding?
a.
Normal finding
b.
Finding requiring a referral
c.
Abnormal finding
d.
Normal finding, but requires rechecking in 1
month
ANS: A
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No further
intervention is required.
DIF: Cognitive Level: Apply
REF: p. 301
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually
closes at which age?
a.
b.
c.
d.
6 to 8 weeks
10 to 12 weeks
4 to 6 months
8 to 10 months
ANS: A
The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks; 10 to 12 weeks,
4 to 6 months, and 8 to 10 months are too late. The posterior fontanel is usually closed by age 8
weeks.
DIF: Cognitive Level: Remember
REF: p. 301
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and
corn are not completely digested and can be seen in their infant’s stools. The nurse’s explanation
of this is based on which statement?
a.
Child should not be given fibrous foods until
digestive tract matures at age 4 years.
b.
Child should not be given any solid foods un
til this digestive problem is resolved.
c.
This is abnormal and requires further investi
gation.
d.
This is normal because of the immaturity of
digestive processes at this age.
ANS: D
The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are
passed incompletely broken down in the feces. An excess quantity of fiber predisposes the child
to large, bulky stools. This is normal for the child and is a normal part of the maturational
process; no further investigation is necessary.
DIF: Cognitive Level: Apply
REF: p. 306
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but
she will not voluntarily grasp it. How should the nurse interpret this action?
a.
Normal development
b.
Significant developmental lag
c.
Slightly delayed development due to prematurity
d.
Suggestive of a neurologic disorder such as
cerebral palsy
ANS: A
Holding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive
grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. The infant
is expected to be able to perform this task by age 3 months. If the child’s age is corrected because
of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task
and the behavior is age appropriate. No evidence of neurologic dysfunction is present.
DIF: Cognitive Level: Apply
REF: p. 306
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. In terms of fine motor development, what should the infant of 7 months be able to do?
a.
Transfer objects from one hand to the other
b.
c.
d.
and bang cubes on a table.
Use thumb and index finger in crude pincer
grasp and release an object at will.
Hold a crayon between the fingers and make
a mark on paper.
Release cubes into a cup and build a tower of
two blocks.
ANS: A
By age 7 months, infants can transfer objects from one hand to the other, crossing the midline,
and bang objects on a hard surface. The crude pincer grasp is apparent at about age 9 months,
and releasing an object at will is seen around 8 months. The child can scribble spontaneously at
age 15 months. At age 12 months, the child can release cubes into a cup and build a small tower.
DIF: Cognitive Level: Understand
REF: p. 306
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. At what age can most infants sit steadily unsupported?
a.
4 months
b.
6 months
c.
8 months
d.
10 months
ANS: C
Sitting erect without support is a developmental milestone usually achieved by 8 months. At age
4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.
DIF: Cognitive Level: Understand
REF: p. 306
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often
prone (face down) while awake. What knowledge should the nurse’s response should be based?
a.
Unacceptable because of the risk of sudden
infant death syndrome (SIDS)
b.
Unacceptable because it does not encourage
achievement of developmental milestones
c.
Acceptable to encourage fine motor develop
ment
d.
Acceptable to encourage head control and
turning over
ANS: D
These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep
on their backs and then be placed on their abdomens when awake to enhance development of
milestones such as head control. The face-down position while awake and on the back for sleep
are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor, development.
DIF: Cognitive Level: Analyze
REF: p. 306
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. By which age should the nurse expect an infant to be able to pull to a standing position?
a.
6 months
b.
8 months
c.
11 to 12 months
d.
14 to 15 months
ANS: C
Most infants can pull themselves to a standing position at age 9 months. Infants who are not able
to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and
legs. By age 8 months, infants can bear full weight on their legs. Any infant who cannot pull to a
standing position by age 1 year should be referred for further evaluation.
DIF: Cognitive Level: Understand
REF: p. 306
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. According to Piaget, the 6-month-old infant should be in which developmental stage?
a.
Use of reflexes
b.
Primary circular reactions
c.
Secondary circular reactions
d.
Coordination of secondary schemata
ANS: C
Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is
characterized by a continuation of the primary circular reaction for the response that results.
Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes is
primarily during the first month of life. Primary circular reaction stage marks the replacement of
reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.
DIF: Cognitive Level: Remember
REF: p. 310
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. A nurse is conducting a teaching session for parents of infants. The nurse explains that which be-
havior indicates that an infant has developed object permanence?
a.
Recognizes familiar face, such as mother
b.
Recognizes familiar object, such as bottle
c.
Actively searches for a hidden object
d.
Secures objects by pulling on a string
ANS: C
During the first 6 months of life, infants believe that objects exist only as long as they can see
them. When infants search for an object that is out of sight, this signals the attainment of object
permanence, whereby an infant knows an object exists even when it is not visible. Between ages
8 and 12 weeks, infants begin to respond differentially to the mother. They cry, smile, vocalize,
and show distinct preference for the mother. This preference is one of the stages that influences
the attachment process but is too early for object permanence. Recognizing familiar objects is an
important transition for the infant, but it does not signal object permanence. The ability to understand cause and effect is part of secondary schemata development.
DIF: Cognitive Level: Understand
REF: p. 313
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. A parent asks the nurse “at what age do most infants begin to fear strangers?” The nurse should
give which response?
a.
b.
c.
d.
2 months
4 months
6 months
12 months
ANS: C
Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are
related to the infant’s ability to discriminate between familiar and unfamiliar people. At 2
months, infants are just beginning to respond differentially to the mother. At age 4 months, the
infant is beginning the process of separation-individuation when the infant begins to recognize
self and mother as separate beings. Twelve months is too late and requires referral for evaluation
if the child does not fear strangers at this age.
DIF: Cognitive Level: Understand
REF: p. 313
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. A 4-month-old was born at 35 weeks of gestation. She seems to be developing normally, but her
parents are concerned because she is a “more difficult” baby than their other child, who was
term. What should the nurse’s explanation include?
a.
Infants’ temperaments are part of their unique
characteristics.
b.
Infants become less difficult if they are not
kept on scheduled feedings and structured
routines.
c.
The infant’s behavior is suggestive of failure
to bond completely with her parents.
d.
The infant’s difficult temperament is the result of painful experiences in the neonatal pe
riod.
ANS: A
Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infant’s unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured
caregiving routines than to demand feedings and frequent changes in routines. The infant’s temperament has been created by both biologic and environmental factors. The nurse should provide
guidance in parenting techniques that are best suited to the infant’s temperament.
DIF: Cognitive Level: Understand
REF: p. 314
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
15. Which information could be given to the parents of a 12-month-old child regarding appropriate
play activities?
a.
b.
c.
d.
Give large push-pull toys for kinetic stimula
tion.
Place cradle gym across crib to facilitate fine
motor skills.
Provide child with finger paints to enhance
fine motor skills.
Provide stick horse to develop gross motor
coordination.
ANS: A
The 12-month-old child is able to pull to standing and walk holding on or independently. Appropriate toys for a child this age include large pull toys for kinesthetic stimulation. A cradle gym
should not be placed across the crib. Finger paints are appropriate for older children. A 12month-old child does not have the stability to use a stick horse.
DIF: Cognitive Level: Apply
REF: p. 314
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
16. The nurse is discussing development and play activities with the parent of a 2-month-old. Rec-
ommendations should include giving a first rattle at about which age?
a.
b.
c.
d.
2 months
4 months
7 months
9 months
ANS: B
It is recommended that a brightly colored toy or rattle be given to the child at age 4 months.
Grasping has begun as a deliberate act, and the infant grasps, holds, and begins shaking to hear a
noise; 2 months is too young. The infant still has primarily reflex grips; 7 to 9 months is too old
for the first rattle. The child should be given toys that provide for further exploration.
DIF: Cognitive Level: Apply
REF: p. 314
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
a.
Playing peek-a-boo
b.
Playing pat-a-cake
c.
Imitating animal sounds
d.
Showing how to clap hands
ANS: A
Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice
this new skill for visual stimulation. Pat-a-cake and showing how to clap hands will help with kinetic stimulation. Imitating animal sounds will help with auditory stimulation.
DIF: Cognitive Level: Apply
REF: p. 314
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Which would be the best play activity for a 6-month-old infant to provide tactile stimulation?
a.
Allow to splash in bath.
b.
Give various colored blocks.
c.
Play music box, tapes, or CDs.
d.
Use infant swing or stroller.
ANS: A
The feel of the water while the infant is splashing will provide tactile stimulation. Various colored blocks would provide visual stimulation for a 4- to 6-month-old infant. Music box, tapes,
and CDs provide auditory stimulation. Swings and strollers provide kinesthetic stimulation.
DIF: Cognitive Level: Apply
REF: p. 309
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
19. At what age should the nurse expect an infant to begin smiling in response to pleasurable stim-
uli?
a.
b.
1 month
2 months
c.
d.
3 months
4 months
ANS: B
At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age
1 month. The 3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.
DIF: Cognitive Level: Understand
REF: p. 314
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
20. At what age does an infant start to recognize familiar faces and objects, such as a feeding bottle?
a.
1 month
b.
2 months
c.
3 months
d.
4 months
ANS: C
The child can recognize familiar objects at approximately age 3 months. For the first 2 months of
life, infants watch and observe their surroundings. The 4-month-old infant is able to anticipate
feeding after seeing the bottle.
DIF: Cognitive Level: Understand
REF: p. 314
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
21. A parent asks the nurse “when will my infant start to teethe?” The nurse responds that the earliest
age at which an infant begins teething with eruption of lower central incisors is _____ months.
a.
4
b.
6
c.
8
d.
12
ANS: B
Teething usually begins at age 6 months with the eruption of the lower central incisors; 4 months
is too early for teething. By age 8 months, the infant has the upper and lower central incisors. At
age 12 months, the infant has six to eight deciduous teeth.
DIF: Cognitive Level: Apply
REF: p. 317
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
22. The nurse is guiding parents in selecting a daycare facility for their infant. Which is especially
important to consider when making the selection?
a.
Health practices of facility
b.
Structured learning environment
c.
Socioeconomic status of children
d.
Cultural similarities of children
ANS: A
Health practices should be most important. With the need for diaper changes and assistance with
feeding, young children are at increased risk when hand washing and other hygienic measures
are not adhered to. A structured learning environment is not suitable for this age child. The socioeconomic status of children should have little effect on the choice of facility. Cultural similarities of children may be important to the families, but the health care practices of the facility are
more important.
DIF: Cognitive Level: Understand
REF: p. 315
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
23. Austin, age 6 months, has six teeth. How should the nurse interpret this finding?
a.
Normal tooth eruption
b.
Delayed tooth eruption
c.
Unusual and dangerous
d.
Earlier-than-normal tooth eruption
ANS: D
Six months is earlier than expected. Most infants at age 6 months have two teeth. Although unusual, it is not dangerous.
DIF: Cognitive Level: Understand
REF: p. 316
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
24. The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, in-
flexible, high-top shoes. The nurse should explain that:
a.
soft and flexible shoes are generally better.
b.
high-top shoes are necessary for support.
c.
inflexible shoes are necessary to prevent intoeing and out-toeing.
d.
this type of shoe will encourage the infant to
walk sooner.
ANS: A
The main purpose of the shoe is protection. Soft, well-constructed, athletic-type shoes are best
for infants and children. High-top shoes are not necessary for support but may help to keep the
child’s foot in the shoe. Inflexible shoes can delay walking and can aggravate in-toeing and outtoeing and impede development of the supportive foot muscles.
DIF: Cognitive Level: Analyze
REF: p. 323
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
25. The nurse should teach parents that which age is safe to give infants whole milk instead of com-
mercial infant formula?
a.
b.
6 months
9 months
c.
d.
12 months
18 months
ANS: C
The American Academy of Pediatrics does not recommend the use of cow’s milk for children
younger than 12 months. At 6 and 9 months, the infant should be receiving commercial infant
formula or breast milk. At age 18 months, milk and formula are supplemented with solid foods,
water, and some fruit juices.
DIF: Cognitive Level: Understand
REF: p. 318
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
26. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What
should the nurse recommend the infant be given?
a.
Skim milk
b.
Whole cow’s milk
c.
Commercial iron-fortified formula
d.
Commercial formula without iron
ANS: C
For children younger than 1 year, the American Academy of Pediatrics recommends the use of
breast milk. If breastfeeding has been discontinued, then iron-fortified commercial formula
should be used. Cow’s milk should not be used in children younger than 12 months. Maternal
iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron-deficiency anemia.
DIF: Cognitive Level: Apply
REF: p. 319
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
27. What is the best age for solid food to be introduced into the infant’s diet?
a.
2 to 3 months
b.
4 to 6 months
c.
When birth weight has tripled
d.
When tooth eruption has started
ANS: B
Physiologically and developmentally, the 4- to 6-month-old infant is in a transition period. The
extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the
gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding; 2 to 3
months is too young. The extrusion reflex is strong, and the child will push food out with the
tongue. Infant birth weight triples at 1 year. Solid foods can be started earlier. Tooth eruption can
facilitate biting and chewing; most infant foods do not require this ability.
DIF: Cognitive Level: Understand
REF: p. 319
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
28. Which information should the nurse give a mother regarding the introduction of solid foods dur-
ing infancy?
a.
b.
c.
d.
Solid foods should not be introduced until 8
to 10 months, when the extrusion reflex begins to disappear.
Foods should be introduced one at a time, at
intervals of 4 to 7 days.
Solid foods can be mixed in a bottle to make
the transition easier for the infant.
Fruits and vegetables should be introduced
into the diet first.
ANS: B
One food item is introduced at intervals of 4 to 7 days to allow the identification of food allergies. Solid foods can be introduced earlier than 8 to 10 months. The extrusion reflex usually disappears by age 6 months. Mixing solid foods in a bottle has no effect on the transition to solid
food. Iron-fortified cereal should be the first solid food introduced into the infant’s diet.
DIF: Cognitive Level: Apply
REF: p. 319
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
29. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will
be able to heat the baby’s formula faster. What should the nurse recommend?
a.
Never heat a bottle in a microwave oven.
b.
Heat only 10 ounces or more.
c.
Always leave bottle top uncovered to allow
heat to escape.
d.
Shake bottle vigorously for at least 30 seconds after heating.
ANS: A
Bottles cannot be heated safely in microwave ovens even if safe guidelines are followed and regardless of the amount to be heated due to uneven heating and possible burns.
DIF: Cognitive Level: Apply
REF: p. 319
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
30. Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned
about this. The nurse’s response should be based on which statement?
a.
Children should not sleep with their parents.
b.
Separation from parents should be completed
by this age.
c.
Daytime attention should be increased.
d.
This is a common and accepted practice, especially in some cultural groups.
ANS: D
Co-sleeping, or sharing the family bed, in which the parents allow the children to sleep with
them, is a common and accepted practice in many cultures. Parents should evaluate the options
available and avoid conditions that place the infant at risk. Population-based studies are currently
under way; no evidence at this time supports or condemns the practice for safety reasons. Cosleeping is a cultural practice. One year is the age at which children are just beginning to individuate. Increased daytime activity may help decrease sleep problems in general, but co-sleeping is
a culturally determined phenomenon.
DIF: Cognitive Level: Understand
REF: p. 321
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
31. The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements
are needed. What is the nurse’s best response?
a.
“She needs to begin taking them now.”
b.
“They are not needed if you drink fluoridated
water.”
c.
“She may need to begin taking them at age 4
months.”
d.
“She can have infant cereal mixed with fluo
ridated water instead of supplements.”
ANS: C
Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at
age 4 months if the child is not drinking adequate amounts of fluoridated water. The amount of
water that is ingested and the amount of fluoride in the water are taken into account when supplementation is being considered.
DIF: Cognitive Level: Apply
REF: p. 321
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
32. The parents of a 12-month-old child ask the nurse whether the child can eat hot dogs. The nurse’s
reply should be based on which statement?
a.
b.
c.
d.
Child is too young to digest hot dogs.
Child is too young to eat hot dogs safely.
Hot dogs must be sliced into sections to prevent aspiration.
Hot dogs must be cut into small, irregular
pieces to prevent aspiration.
ANS: D
Hot dogs are of a consistency, diameter, and round shape that may cause complete obstruction of
the child’s airway. If given to young children, the hot dog should be cut into small irregular
pieces rather than served whole or in slices. The child’s digestive system is mature enough to digest hot dogs. To eat the hot dog safely, the child should be sitting down, and the hot dog should
be appropriately cut.
DIF: Cognitive Level: Apply
REF: p. 325
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control (Injury
Prevention)
33. The clinic is lending a federally approved car seat to an infant’s family. The nurse should explain
that the safest place to put the car seat is:
a.
b.
c.
d.
front facing in back seat.
rear facing in back seat.
front facing in front seat with air bag on pas
senger side.
rear facing in front seat if an air bag is on the
passenger side.
ANS: B
The rear-facing car seat provides the best protection for an infant’s disproportionately heavy head
and weak neck. The middle of the back seat is the safest position for the child. The infant must
be rear facing to protect the head and neck in the event of an accident. Severe injuries and deaths
in children have occurred from air bags deploying on impact in the front passenger seat.
DIF: Cognitive Level: Understand
REF: p. 325
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
34. Which figure depicts an expected developmental milestone for a 7-month-old infant?
a.
b.
c.
d.
ANS: A
By 6 to 7 months of age, infants are able to bear all their weight on their legs with assistance. Infants can stand holding on to furniture at 9 months. While standing, the infant takes a deliberate
step at 10 months. Crawling (propelling forward with the belly on the floor) progresses to creeping on hands and knees (with the belly off of the floor) by 9 months.
DIF: Cognitive Level: Analyze
REF: p. 311
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is teaching parents about appropriate pacifier selection. Which characteristics should
the pacifier have? (Select all that apply.)
a.
b.
c.
d.
e.
Easily grasped handle
One-piece construction
Ribbon or string to secure to clothing
Soft, pliable material
Sturdy, flexible material
ANS: A, B, E
A good pacifier should be easily grasped by the infant. One-piece construction is necessary to
avoid having the nipple and guard separate. The material should be sturdy and flexible. If the
pacifier is too pliable, it may be aspirated. No ribbon or string should be attached. This poses additional risks.
DIF: Cognitive Level: Apply
REF: p. 316
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
2. In terms of gross motor development, which should the nurse expect a 5-month-old infant to do?
(Select all that apply.)
a.
b.
c.
d.
e.
f.
Roll from abdomen to back.
Put feet in mouth when supine.
Roll from back to abdomen.
Sit erect without support.
Move from prone to sitting position.
Adjust posture to reach an object.
ANS: A, B
Rolling from abdomen and to back and placing the feet in the mouth when supine are developmentally appropriate for a 5-month-old infant. The ability to roll from back to abdomen usually
occurs at 6 months old. Sitting erect without support is a developmental milestone usually
achieved by 8 months. The 10-month-old infant can usually move from a prone to a sitting position. The 8-month-old infant adjusts posture to reach an object.
DIF: Cognitive Level: Apply
REF: p. 308
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is teaching a parent about administration of iron supplements to a 7-month-old infant.
Which should the nurse include in the teaching session? (Select all that apply.)
Administer the iron supplement with a dropper toward the side and to the back of the
mouth
b.
Administer the iron supplement with feedings.
c.
Your infant’s stools may look tarry green.
d.
Your infant may have some diarrhea initially.
e.
Follow the iron supplement with 4 ounces of
juice.
a.
ANS: A, C, E
Liquid iron supplements may stain the teeth; therefore, administer them with a dropper toward
the back of the mouth (side). Ideally, iron supplements should be administered between meals for
greater absorption. Avoid administration of liquid iron supplements with whole cow’s milk or
milk products because they bind free iron and prevent absorption. Educate parents that iron supplements will turn stools black or tarry green. Iron supplements may cause transient constipation,
not diarrhea. In older children, follow liquid iron supplement with a citrus fruit or juice drink (no
more than 3 to 4 oz).
DIF: Cognitive Level: Apply
REF: p. 318
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is teaching a parent about introduction of solid foods into an infant’s diet. Which should
the nurse include in the teaching session? (Select all that apply.)
a.
Solid food introduction can be started at 2
months of age.
b.
Rice cereal is introduced first.
c.
Begin the introduction of solid foods by mix
ing with formula in the bottle.
d.
Introduce egg white in small quantities (1 tsp)
toward the end of the first year.
e.
Introduce one food at a time, usually at inter
vals of 4 to 7 days.
ANS: B, D, E
Rice cereal, because of its low allergenic potential, is the first solid food introduced to an infant
at 4 to 6 months of age. Introduce one food at a time, usually at intervals of 4 to 7 days, to identify food allergies. Introduce egg white in small quantities (1 tsp) toward the end of the first year
to detect an allergy. Solid food introduction should be started at 4 to 6 months of age. Never introduce foods by mixing them with the formula in a bottle.
DIF: Cognitive Level: Apply
REF: p. 319
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the expected sequence of fine motor developmental milestones for an infant begin-
ning with the first milestone achieved and ending with the last milestone achieved. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d, e).
a. Voluntary palmar grasp
b. Reflex palmar grasp
c. Puts objects into a container
d. Neat pincer grasp
e. Builds a tower of two blocks, but fails
ANS:
b, a, d, c, e
Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 5
months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using the
whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months
of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a neat pincer
grasp. By 11 months, they put objects into containers and like to remove them. By age 1 year, infants try to build towers of two blocks but fail.
DIF: Cognitive Level: Analyze
REF: p. 307
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 10: Health Problems of Infants
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Recent studies indicate that a deficiency of which vitamin correlates with increased morbidity
and mortality in children with measles?
a.
b.
c.
d.
A
C
Niacin
Folic acid
ANS: A
Vitamin A deficiency is correlated with increased morbidity and mortality in children with
measles. This vitamin deficiency also is associated with complications from diarrhea, and infections are often increased in infants and children with vitamin A deficiency. No correlation exists
between vitamin C, niacin, or folic acid and measles.
DIF: Cognitive Level: Remember
REF: p. 331
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. Which vitamin is recommended for all women of childbearing age to reduce the risk of neural
tube defects such as spina bifida?
a.
b.
c.
d.
A
C
Niacin
Folic acid
ANS: D
The vitamin supplement that is recommended for all women of childbearing age is a daily dose
of 0.4 mg of folic acid. Folic acid taken before conception and during pregnancy can reduce the
risk of neural tube defects by 70%. No correlation exists between vitamins A, C, or folic acid and
neural tube defects.
DIF: Cognitive Level: Remember
REF: p. 331
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
3. A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the
nurse expect?
a.
b.
c.
d.
Thin wasted extremities with a prominent ab
domen
Constipation
Elevated hemoglobin
High levels of protein
ANS: A
The child with kwashiorkor has thin, wasted extremities and a prominent abdomen from edema
(ascites). Diarrhea (persistent diarrhea malnutrition syndrome) not constipation commonly occurs from a lowered resistance to infection and further complicates the electrolyte imbalance.
Anemia and protein deficiency are common findings in malnourished children with kwashiorkor.
DIF: Cognitive Level: Understand
REF: p. 332
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. A nurse is preparing to accompany a medical mission’s team to a third world country. Marasmus
is seen frequently in children 6 months to 2 years in this country. Which symptoms should the
nurse expect for this condition?
a.
Loose, wrinkled skin
b.
Edematous skin
c.
Depigmentation of the skin
d.
Dermatoses
ANS: A
Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears to be very old, with loose and wrinkled skin, unlike the child
with kwashiorkor, who appears more rounded from the edema. Fat metabolism is less impaired than in kwashiorkor; thus, deficiency of fat-soluble vitamins is usually minimal or absent. In general, the clinical manifestations of marasmus are similar to those seen in kwashiorkor with the following exceptions: With marasmus, there is no edema from hypoalbuminemia or sodium retention, which contributes to a severely emaciated appearance; no dermatoses caused by vitamin deficiencies; little or no depigmentation of hair or skin; moderately normal fat metabolism and lipid absorption; and a smaller head size and slower recovery after treatment.
DIF: Cognitive Level: Understand
REF: p. 332
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
5. Rickets is caused by a deficiency in:
a.
b.
c.
d.
ANS: C
vitamin A.
vitamin C.
vitamin D and calcium.
folic acid and iron.
Fat-soluble vitamin D and calcium are necessary in adequate amounts to prevent the development of rickets. No correlation exists between vitamins A, C, folic acid, or iron and rickets.
DIF: Cognitive Level: Remember
REF: p. 330
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
6. A nurse is preparing to administer an oral iron supplement to a hospitalized infant. Which should
not be given simultaneously with the iron supplement?
a.
Milk
b.
Multivitamin
c.
Fruit juice
d.
Meat, fish, poultry
ANS: A
Many foods interfere with iron absorption and should be avoided when the iron is consumed.
These foods include phosphates found in milk, phytates found in cereals, and oxalates found in
many vegetables. Multivitamins may contain iron; no contraindication exists to taking the two
together. Vitamin C–containing juices enhance the absorption of iron. Meat, fish, and poultry do
not have an effect on absorption.
DIF: Cognitive Level: Understand
REF: p. 331
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse
counsels the parents that which vitamin can cause a toxic reaction at a low dose?
Niacin
B6
D
C
a.
b.
c.
d.
ANS: C
Hypervitaminosis of vitamin D presents the greatest problem because this fat-soluble vitamin is
stored in the body. Vitamin D is the most likely of all vitamins to cause toxic reactions in relatively small overdoses. The water-soluble vitamins, primarily niacin, B6, and C, can also cause
toxicity but not at the low dose that occurs with vitamin D.
DIF: Cognitive Level: Understand
REF: p. 331
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
8. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child.
Which is most likely lacking in their particular diet?
a.
Fat
b.
Protein
c.
Vitamins C and A
d.
Complete protein
ANS: D
The vegetarian diet can be extremely healthy, meeting the overall nutrition objectives for
Healthy People. Parents should be taught about food preparation to ensure that complete proteins
are available for growth. When parents use a strict vegetarian diet, likelihood exists of inadequate
protein for growth and calories for energy. Fat and vitamins C and A are readily available from
vegetable sources. Plant proteins are available. Foods must be combined to provide complete
proteins for growth.
DIF: Cognitive Level: Understand
REF: p. 331
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
9. Which describes marasmus?
a.
b.
c.
d.
Deficiency of protein with an adequate supply
of calories
Not confined to geographic areas where food
supplies are inadequate
Syndrome that results solely from vitamin de
ficiencies
Characterized by thin, wasted extremities and
a prominent abdomen resulting from edema
(ascites)
ANS: B
Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic
areas were food supplies are inadequate. Marasmus is a deficiency of both protein and calories. It
is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat.
The child appears very old, with flabby and wrinkled skin.
DIF: Cognitive Level: Remember
REF: p. 332
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
10. Although infants may be allergic to a variety of foods, the most common allergens are:
a.
fruit and eggs.
b.
fruit, vegetables, and wheat.
c.
cow’s milk and green vegetables.
d.
eggs, cow’s milk, and wheat.
ANS: D
Milk products, eggs, and wheat are three of the most common food allergens. Ingestion of these
products can cause sensitization and, with subsequent exposure, an allergic reaction. Eggs are a
common allergen, but fruit is not. Wheat is a common allergen, but fruit and vegetables are not.
Cow’s milk is a common allergen, but green vegetables are not.
DIF: Cognitive Level: Remember
REF: p. 333
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
11. Cow’s milk allergy (CMA) is diagnosed in a 6-month-old infant. Which should the nurse recom-
mend as a substitute formula?
a.
b.
c.
d.
Nutramigen
Goat’s milk
Similac
Enfamil
ANS: A
Treatment of CMA is elimination of cow’s milk–based formula and all other dairy products. For
infants fed cow’s milk formula, this primarily involves changing the formula to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum). Goat’s milk (raw) is not an acceptable substitute because it cross-reacts with cow’s milk protein, is deficient in folic acid, has a
high sodium and protein content, and is unsuitable as the only source of calories. Cow’s milk
protein is contained in both Enfamil and Similac.
DIF: Cognitive Level: Apply
REF: p. 336
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
12. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse in-
clude in the teaching plan?
a.
b.
c.
d.
Avoid use of pacifiers.
Eliminate all second-hand smoke contact.
Lay infant flat after feeding.
Avoid swaddling the infant.
ANS: B
To prevent and treat colic, teach parents that if household members smoke, avoid smoking near
infant; preferably confine smoking activity to outside of home. A pacifier can be introduced for
added sucking. The infant should be swaddled tightly with a soft, stretchy blanket and placed in
an upright seat after feedings.
DIF: Cognitive Level: Apply
REF: p. 336
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
13. A parent of an infant with colic tells the nurse, “All this baby does is scream at me; it is a con-
stant worry.” What is the nurse’s best action?
Encourage parent to verbalize feelings.
Encourage parent not to worry so much.
Assess parent for other signs of inadequate
parenting.
d.
Reassure parent that colic rarely lasts past age
9 months.
a.
b.
c.
ANS: A
Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An
empathic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help al-
leviate the parent’s anxieties. The nurse should reassure the parent that he or she is not doing
anything wrong. Colic is multifactorial. The infant with colic is experiencing spasmodic pain that
is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will
eventually go away does not help him or her through the current situation.
DIF: Cognitive Level: Apply
REF: p. 342
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
14. Parent guidelines for relieving colic in an infant include:
a.
avoiding touching abdomen.
b.
avoiding using a pacifier.
c.
changing infant’s position frequently.
d.
placing infant where family cannot hear the
crying.
ANS: C
Changing the infant’s position frequently may be beneficial. The parent can walk holding the
child face down and with the child’s chest across the parent’s arm. The parent’s hand can support
the child’s abdomen, applying gentle pressure. Gently massaging the abdomen is effective in
some children. Pacifiers can be used for meeting additional sucking needs. The child should not
be placed where monitoring cannot be done. The child can be placed in the crib and allowed to
cry. Periodically, the child should be picked up and comforted.
DIF: Cognitive Level: Apply
REF: p. 342
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
15. Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate
intake of calories include:
a.
b.
c.
d.
avoidance of eye contact.
an associated malabsorption defect.
weight that falls below the 15th percentile.
normal achievement of developmental landmarks.
ANS: A
One of the clinical manifestations of nonorganic failure to thrive is the child’s avoidance of eye
contact with the health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is indicative of failure to
thrive. Developmental delays, including social, motor, adaptive, and language, exist.
DIF: Cognitive Level: Understand
REF: p. 337
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
16. Which is an important nursing consideration when caring for an infant with failure to thrive?
a.
Establish a structured routine and follow it
consistently.
b.
c.
d.
Maintain a nondistracting environment by not
speaking to child during feeding.
Place child in an infant seat during feedings
to prevent overstimulation.
Limit sensory stimulation and play activities
to alleviate fatigue.
ANS: A
The infant with failure to thrive should have a structured routine that is followed consistently.
Disruptions in other activities of daily living can have a great impact on feeding behaviors.
Bathing, sleeping, dressing, playing, and feeding are structured. The nurse should talk to the
child by giving directions about eating. This will help the child maintain focus. Young children
should be held while being fed, and older children can sit at a feeding table. The child should be
fed in the same manner at each meal. The child can engage in sensory and play activities at times
other than mealtime.
DIF: Cognitive Level: Apply
REF: p. 337
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
17. What is an important nursing responsibility when dealing with a family experiencing the loss of
an infant from sudden infant death syndrome (SIDS)?
Explain how SIDS could have been predicted
and prevented.
b.
Interview parents in depth concerning the cir
cumstances surrounding the child’s death.
c.
Discourage parents from making a last visit
with the infant.
d.
Make a follow-up home visit to parents as
soon as possible after the child’s death.
a.
ANS: D
A competent, qualified professional should visit the family at home as soon as possible after the
death and provide the family with printed information about SIDS. An explanation of how SIDS
could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked
only factual questions to determine the cause of death. Parents should be allowed and encouraged
to make a last visit with their child.
DIF: Cognitive Level: Apply
REF: p. 343
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
18. Which is an appropriate action when an infant becomes apneic?
a.
Shake vigorously
b.
Roll head side to side
c.
Hold by feet upside down with head sup-
ported
d.
Gently stimulate trunk by patting or rubbing
ANS: D
If the infant is apneic, the infant’s trunk should be gently stimulated by patting or rubbing. If the
infant is prone, turn onto the back. The infant should not be shaken vigorously, the head rolled
side to side, or held by the feet upside down with the head supported. These can cause injury.
DIF: Cognitive Level: Apply
REF: p. 349
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
19. To prevent plagiocephaly, the nurse should teach parents to:
a.
place infant prone for 30 to 60 minutes per
b.
c.
d.
day.
buy a soft mattress.
allow infant to nap in the car safety seat.
have infant sleep with the parents.
ANS: A
Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or “tummy time” for approximately 30 to 60 minutes per day when the infant is awake.
Soft mattresses or sleeping with parents (co-sleeping) are not recommended because they put the
infant at a higher risk for a sudden infant death incident. To prevent plagiocephaly, prolonged
placement in car safety seats should be avoided.
DIF: Cognitive Level: Apply
REF: p. 348
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
20. An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emer-
gency department. Which is an appropriate question to ask the parents?
“Did you hear the infant cry out?”
“Why didn’t you check on the infant earlier?”
“What time did you find the infant?”
“Was the head buried in a blanket?”
a.
b.
c.
d.
ANS: C
During a SIDS incident, if the infant is not pronounced dead at the scene, he or she may be transported to the emergency department to be pronounced dead by a physician. While they are in the
emergency department, the parents are asked only factual questions, such as when they found the
infant, how he or she looked, and whom they called for help. The nurse avoids any remarks that
may suggest responsibility, such as “Why didn’t you go in earlier?” “Didn’t you hear the infant
cry out?” “Was the head buried in a blanket?”
DIF: Cognitive Level: Apply
REF: p. 347
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
21. An infant experienced an apparent life-threatening event (ALTE) and is being placed on home
apnea monitoring. Parents have understood the instructions for use of a home apnea monitor
when they state?
a.
“We can adjust the monitor to eliminate false
alarms.”
b.
“We should sleep in the same bed as our mon
itored infant.”
c.
“We will check the monitor several times a
day to be sure the alarm is working.”
d.
“We will place the monitor in the crib with
our infant.”
ANS: C
The parents should check the monitor several times a day to be sure the alarm is working and
that it can be heard from room to room. The parents should not adjust the monitor to eliminate
false alarms. Adjustments could compromise the monitor’s effectiveness. The monitor should be
placed on a firm surface away from the crib and drapes. The parents should not sleep in the same
bed as the monitored infant.
DIF: Cognitive Level: Apply
REF: p. 349
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
22. What should the nurse suggest to the parents of an infant who has a prolonged need for middle-
of-the-night feedings?
a.
b.
c.
d.
Decrease daytime feedings.
Allow child to go to sleep with a bottle.
Offer last feeding as late as possible at night.
Put infant to bed after asleep from rocking.
ANS: C
To manage an infant who has a prolonged need for middle-of-the-night feedings parents should
be taught to offer last feeding as late as possible at night. Parent should increase daytime feeding
intervals to 4 hours or more (may need to be done gradually), offer no bottles in bed, put to bed
awake and when child is crying, check at progressively longer intervals each night; reassure child
but do not hold, rock, take to parent’s bed, or give bottle or pacifier.
DIF: Cognitive Level: Apply
REF: p. 349
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
23. A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention
should the nurse implement?
a.
b.
c.
d.
ANS: D
Provide stimulation during feeding.
Avoid being persistent during feeding time.
Limit feeding time to 10 minutes.
Maintain a face-to-face posture with the infant during feeding.
The nurse preparing to feed an infant with failure to thrive should maintain a face-to-face posture
with the infant when possible. Encourage eye contact and remain with the infant throughout the
meal. Stimulation is not recommended; a quiet, unstimulating atmosphere should be maintained.
Persistence during feeding may need to be implemented. Calm perseverance through 10 to 15
minutes of food refusal will eventually diminish negative behavior. Although forced feeding is
avoided, “strictly encouraged” feeding is essential. The length of the feeding should be established (usually 30 minutes); limiting the feeding to 10 minutes would make the infant feel
rushed.
DIF: Cognitive Level: Apply
REF: p. 342
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
24. A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap).
Which should the nurse include in the instructions?
a.
Shampoo every three days with a mild soap.
b.
The hair should be shampooed with a medicated shampoo.
c.
Shampoo every day with an antiseborrheic
shampoo.
d.
The loosened crusts should not be removed
with a fine-toothed comb.
ANS: C
When seborrheic lesions are present, the treatment is directed at removing the crusts. Parents are
taught the appropriate procedure to clean the scalp. Shampooing should be done daily with a
mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the
scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly
rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands
of hair after shampooing.
DIF: Cognitive Level: Apply
REF: p. 346
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been
noted of which of the following pediatric disorders? (Select all that apply.)
a.
SIDS
b.
Torticollis
c.
Failure to thrive
d.
Apnea of infancy
e.
Plagiocephaly
ANS: B, E
Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull. If
that side becomes misshapen, facial asymmetry may result. The sternocleidomastoid muscle may
tighten on the affected side, causing torticollis. SIDS has decreased by more than 40% with the
introduction of the Back to Sleep campaign. Apnea of infancy and failure to thrive are unrelated
to the Back to Sleep campaign.
DIF: Cognitive Level: Understand
REF: p. 346
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden
infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant’s risk of a sudden infant death syndrome incident? (Select all that apply.)
a.
Breastfeeding
b.
Low Apgar scores
c.
Male sex
d.
Birth weight in the 50th or higher percentile
e.
Recent viral illness
ANS: B, C, E
Certain groups of infants are at increased risk for SIDS: low birth weight, low Apgar scores, recent viral illness, and male sex. Breastfed infants and infants of average or above average weight
are not at higher risk for SIDS.
DIF: Cognitive Level: Understand
REF: p. 336
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. An infant has been diagnosed with cow’s milk allergy. What are the clinical manifestations the
nurse expects to assess? (Select all that apply.)
a.
Pink mucous membranes
b.
Vomiting
c.
Rhinitis
d.
Abdominal pain
e.
Moist skin
ANS: B, C, D
An infant with cow’s milk allergy will possibly have vomiting, rhinitis, and abdominal pain. The
mucous membranes may be pale due to anemia from blood lost in the GI tract, and the skin will
be itchy with the possibility of atopic dermatitis.
DIF: Cognitive Level: Understand
REF: p. 346
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. Which interventions should the nurse implement when caring for a family of a sudden infant
death syndrome (SIDS) infant? (Select all that apply.)
Allow parents to say goodbye to their infant.
Once parents leave the hospital, no further
follow-up is required.
a.
b.
c.
d.
e.
Arrange for someone to take the parents
home from the hospital.
Avoid requesting an autopsy of the deceased
infant.
Conduct a debriefing session with the parents
before they leave the hospital.
ANS: A, C, E
An important aspect of compassionate care for parents experiencing a SIDS incident is allowing
them to say good-bye to their infant. These are the parents’ last moments with their infant, and
they should be as quiet, meaningful, peaceful, and undisturbed as possible. Because the parents
leave the hospital without their infant, it is helpful to accompany them to the car or arrange for
someone else to take them home. A debriefing session may help health care workers who dealt
with the family and deceased infant to cope with emotions that are often engendered when a
SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional
should visit them after the death as soon as possible.
DIF: Cognitive Level: Understand
REF: p. 340
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
5. Where do the lesions of atopic dermatitis (eczema) most commonly occur in the infant? (Select
all that apply.)
a.
b.
c.
d.
e.
f.
Cheeks
Buttocks
Extensor surfaces of arms and legs
Back
Trunk
Scalp
ANS: A, C, E, F
The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the
cheeks, scalp, trunk, and extensor surfaces of the extremities. The buttocks and back are not
common locations for the lesions of atopic dermatitis in infants.
DIF: Cognitive Level: Understand
REF: p. 340
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema). Which re-
sponse(s) should the nurse reinforce with the parent? (Select all that apply.)
a.
“You can use warm wet compresses to relieve
discomfort.”
b.
“You will need to keep your infant’s skin well
hydrated by using a mild soap in the bath.”
c.
“You should bathe your baby in a bubble bath
two times a day.”
d.
e.
f.
“You will need to prevent your baby from
scratching the area by using a mild antihistamine.”
“You can try a fabric softener in the laundry
to avoid rough cloth.”
“You should apply an emollient to the skin
immediately after a bath.”
ANS: B, D, F
The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection; an antihistamine can be used. Keeping the skin hydrated is a goal
of treating atopic dermatitis. Applying an emollient immediately after a bath helps to trap moisture and prevent moisture loss. Cool wet compresses should be used for relief. Bubble baths and
harsh soaps should be avoided, as is bathing excessively, since this leads to drying. Fabric softener should be avoided because of the irritant effects of some of its components.
DIF: Cognitive Level: Apply
REF: p. 340
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
SHORT ANSWER
1. An infant is having an anaphylactic reaction, and the nurse is preparing to administer epinephrine
0.001 mg/kg. The child weighs 22 pounds. What is the epinephrine dose the nurse should administer? (Record your answer using two decimal places.)
ANS:
0.01
Convert the 22 pounds to kilograms by dividing 22 by 2.2 = 10. Multiply the 10 by 0.001 mg of
epinephrine = 0.01 mg as the dose to be given.
DIF: Cognitive Level: Apply
REF: p. 334
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
OTHER
1. A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyan-
otic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse
should implement in order of the highest priority to the lowest priority. Provide answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Call Jason’s parents and notify them of the situation.
b. Call Jason’s family practitioner to obtain further orders for medication.
c. Promptly administer an intramuscular dose of epinephrine.
d. Call 911 and wait for the emergency response personnel to arrive.
ANS:
c, d, b, a
The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious
distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The
physician should be contacted for further orders and, last, the parents notified of the situation.
DIF: Cognitive Level: Apply
REF: p. 350
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 11: Health Promotion of the Toddler and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which factor is most important in predisposing toddlers to frequent infections?
a. Respirations are abdominal.
b. Pulse and respiratory rates are slower than those in infancy.
c. Defense mechanisms are less efficient than those during infancy.
d. Toddlers have a short, straight internal ear canal and large lymph tissue.
ANS: D
Toddlers continue to have the short, straight internal ear canal of infants. The lymphoid tissue
of the tonsils and adenoids continues to be relatively large. These two anatomic conditions
combine to predispose the toddler to frequent infections. The abdominal respirations and
lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection.
The defense mechanisms are more efficient compared with those of infancy.
DIF: Cognitive Level: Analyze
REF: p. 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. The psychosocial developmental tasks of toddlerhood include which characteristic?
a. Development of a conscience
b. Recognition of sex differences
c. Ability to get along with age-mates
d. Ability to delay gratification
ANS: D
If the need for basic trust has been satisfied, then toddlers can give up dependence for control,
independence, and autonomy. One of the tasks that the toddler is concerned with is the ability
to delay gratification. Development of a conscience occurs during the preschool years. The
recognition of sex differences occurs during the preschool years. The ability to get along with
age-mates develops during the preschool and school-age years.
DIF: Cognitive Level: Understand
REF: p. 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The child of 15 to 30 months is likely to be struggling with which developmental task?
a. Trust
b. Initiative
c. Autonomy
d. Intimacy
ANS: C
Autonomy vs shame and doubt is the developmental task of toddlers. Trust vs mistrust is the
developmental stage of infancy. Initiative vs guilt is the developmental stage of early
childhood. Intimacy and solidarity vs isolation is the developmental stage of early adulthood.
DIF: Cognitive Level: Remember
REF: p. 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A parent of an 18-month-old boy tells the nurse that he says “no” to everything and has rapid
mood swings. If he is scolded, he shows anger and then immediately wants to be held. The
nurse’s best interpretation of this behavior is included in which statement?
a. This is normal behavior for his age.
b. This is unusual behavior for his age.
c. He is not effectively coping with stress.
d. He is showing he needs more attention.
ANS: A
Toddlers use distinct behaviors in the quest for autonomy. They express their will with
continued negativity and the use of the word “no.” Children at this age also have rapid mood
swings. The nurse should reassure the parents that their child is engaged in expected behavior
for an 18-month-old. Having a rapid mood swing is an expected behavior for a toddler.
DIF: Cognitive Level: Understand
REF: p. 358
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. A nurse is planning care for a 17-month-old child. According to Piaget, which stage should
the nurse expect the child to be in cognitively?
Trust
Preoperational
Secondary circular reaction
Tertiary circular reaction
a.
b.
c.
d.
ANS: D
The 17-month-old child is in the fifth stage of the sensorimotor phase, tertiary circular
reactions. The child uses active experimentation to achieve previously unattainable goals.
Trust is Erikson’s first stage. Preoperational is the stage of cognitive development usually
present in older toddlers and preschoolers. Secondary circular reactions last from about ages
4 to 8 months.
DIF: Cognitive Level: Remember
REF: p. 356
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which is descriptive of a toddler’s cognitive development at age 20 months?
a. Searches for an object only if he or she sees it being hidden
b. Realizes that “out of sight” is not out of reach
c. Puts objects into a container but cannot take them out
d. Understands the passage of time, such as “just a minute” and “in an hour”
ANS: B
At this age, the child is in the final sensorimotor stage. Children will now search for an object
in several potential places, even though they saw only the original hiding place. Children
have a more developed sense of objective permanence. They will search for objects even if
they have not seen them hidden. When a child puts objects into a container but cannot take
them out, this is indicative of tertiary circular reactions. An embryonic sense of time exists,
although the children may behave appropriately to time-oriented phrases; their sense of
timing is exaggerated.
DIF: Cognitive Level: Understand
REF: p. 356
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Although a 14-month-old girl received a shock from an electric outlet recently, her parent
finds her about to place a paper clip in another outlet. Which is the best interpretation of this
behavior?
a. Her cognitive development is delayed.
b. This is typical behavior because toddlers are not very developed.
c. This is typical behavior because of the inability to transfer knowledge to new
situations.
d. This is not typical behavior because toddlers should know better than to repeat an
act that caused pain.
ANS: C
During the tertiary circular reactions stage, children have only a rudimentary sense of the
classification of objects. The appearance of an object denotes its function for these children.
The slot of an outlet is for putting things into. Her cognitive development is appropriate for
her age. Trying to put things into an outlet is typical behavior for a toddler. Only some
awareness exists of a causal relation between events.
DIF: Cognitive Level: Understand
REF: p. 356
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other
child. Which is the best interpretation of this behavior?
This is typical behavior because toddlers are aggressive.
This is typical behavior because toddlers are egocentric.
Toddlers should know that sharing toys is expected of them.
Toddlers should have the cognitive ability to know right from wrong.
a.
b.
c.
d.
ANS: B
Play develops from the solitary play of infancy to the parallel play of toddlers. The toddler
plays alongside other children, not with them. This typical behavior of the toddler is not
intentionally aggressive. Shared play is not within their cognitive development. Toddlers do
not conceptualize shared play. Because the toddler cannot view the situation from the
perspective of the other child, it is okay to take the toy. Therefore, no right or wrong is
associated with taking a toy.
DIF: Cognitive Level: Analyze
REF: p. 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Steven, 16 months old, falls down a few stairs. He gets up and “scolds” the stairs as if they
caused him to fall. This is an example of which of the following?
a. Animism
b. Ritualism
c. Irreversibility
d. Delayed cognitive development
ANS: A
Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the
toddler is attributing human characteristics to them. Ritualism is the need to maintain the
sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the
inability to reverse or undo actions initiated physically. Steven is acting in an age-appropriate
manner.
DIF: Cognitive Level: Understand
REF: p. 357
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Which should the nurse expect for a toddler’s language development at age 18 months?
a. Vocabulary of 25 words
b. Increasing level of comprehension
c. Use of holophrases
d. Approximately one third of speech understandable
ANS: B
During the second year of life, level of comprehension and understanding of speech increases
and is far greater than the child’s vocabulary. This is also true for bilingual children, who are
able to achieve this linguistic milestone in both languages. The 18-month-old child has a
vocabulary of 10 or more words. At this age, the child does not use the one-word sentences
that are characteristic of the 1-year-old child. The child has a limited vocabulary of single
words that are comprehensible.
DIF: Cognitive Level: Understand
REF: p. 359
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Which statement is correct about toilet training?
a. Bladder training is usually accomplished before bowel training.
b. Wanting to please the parent helps motivate the child to use the toilet.
c. Watching older siblings use the toilet confuses the child.
d. Children must be forced to sit on the toilet when first learning.
ANS: B
Voluntary control of the anal and urethral sphincters is achieved sometime after the child is
walking. The child must be able to recognize the urge to let go and to hold on. The child must
want to please parent by holding on rather than pleasing self by letting go. Bowel training
precedes bladder training. Watching older siblings provides role modeling and facilitates
imitation for the toddler. The child should be introduced to the potty chair or toilet in a
nonthreatening manner.
DIF: Cognitive Level: Understand
REF: p. 360
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. Which characteristic best describes the gross motor skills of a 24-month-old child?
a. Skips and can hop in place on one foot
b. Rides tricycle and broad jumps
c. Jumps with both feet and stands on one foot momentarily
d. Walks up and down stairs and runs with a wide stance
ANS: D
The 24-month-old child can go up and down stairs alone with two feet on each step and runs
with a wide stance. Skipping and hopping on one foot are achieved by 4-year-old children.
Jumping with both feet and standing on one foot momentarily are achieved by 30-month-old
children. Tricycle riding and broad jumping are achieved at age 3.
DIF: Cognitive Level: Remember
REF: p. 361
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to
make a tower out of blocks. What should the nurse recognize in this situation?
Blocks at this age are used primarily for throwing
Toddlers are too young to imitate the behavior of others
Toddlers are capable of building a tower of blocks
Toddlers are too young to build a tower of blocks
a.
b.
c.
d.
ANS: C
Building with blocks is a good parent-child interaction. The 18-month-old child is capable of
building a tower of three or four blocks. The ability to build towers of blocks usually begins
at age 15 months. With ongoing development, the child is able to build taller towers. The 18month-old child imitates others around him or her.
DIF: Cognitive Level: Apply
REF: p. 360
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
14. At what age should the nurse expect a child to give both first and last names when asked?
a.
b.
c.
d.
15 months
18 months
24 months
30 months
ANS: D
At 30 months, the child is able to give both first and last names and refer to self with an
appropriate pronoun. At 15 and 18 months, the child is too young to give his or her own
name. At 24 months, the child is able to give first name and refer to self by that name.
DIF: Cognitive Level: Understand
REF: p. 362
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. The parents of a newborn say that their toddler “hates the baby; he suggested that we put him
in the trash can so the trash truck could take him away.” Which is the nurse’s best reply?
a. “Let’s see if we can figure out why he hates the new baby.”
b. “That’s a strong statement to come from such a small boy.”
c. “Let’s refer him to counseling to work this hatred out. It’s not a normal response.”
d. “That is a normal response to the birth of a sibling. Let’s look at ways to deal with
this.”
ANS: D
The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers
have their entire schedule and routines disrupted because of the new family member. The
nurse should work with parents on ways to involve the toddler in the newborn’s care and to
help focus attention on the toddler. The toddler does not hate the infant. This is an expected
response to the changes in routines and attention that affect the toddler. The toddler can be
provided with a doll to tend to the doll’s needs at the same time the parent is performing
similar care for the newborn.
DIF: Cognitive Level: Apply
REF: p. 363
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A toddler’s parent asks the nurse for suggestions on dealing with temper tantrums. Which is
the most appropriate recommendation?
a. Punish the child.
b. Leave the child alone until the tantrum is over.
c. Remain close by the child but without eye contact.
d. Explain to child that this is wrong.
ANS: C
The parent should be told that the best way to deal with temper tantrums is to ignore the
behaviors, provided that the actions are not dangerous to the child. Tantrums are common in
toddlers as the child becomes more independent and overwhelmed by increasingly complex
tasks. The parents and caregivers need to have consistent and developmentally appropriate
expectations. Punishment and explanations will not be beneficial. The parent’s presence is
necessary both for safety and to provide a feeling of control and security to the child when
the tantrum is over.
DIF: Cognitive Level: Apply
REF: p. 364
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. A parent asks the nurse about negativism in toddlers. Which is the most appropriate
recommendation?
Punish the child.
Provide more attention.
Ask child not always to say “no.”
Reduce the opportunities for a “no” answer.
a.
b.
c.
d.
ANS: D
The nurse should suggest to the parent that questions be phrased with realistic choices rather
than yes or no answers. This provides the toddler with a sense of control and reduces the
opportunity for negativism. Negativism is not an indication of stubbornness or insolence and
should not be punished. The negativism is not a function of attention; the child is testing
limits to gain an understanding of the world. The toddler is too young to be asked to not
always say “no.”
DIF: Cognitive Level: Apply
REF: p. 364
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Which technique is best for dealing with the negativism of the toddler?
a. Offer the child choices.
b. Remain serious and intent.
c. Provide few or no choices for child.
d. Quietly and calmly ask the child to comply.
ANS: A
The child should have few opportunities to respond in a negative manner. Questions and
requests should provide choices. This allows the child to be in control and reduces
opportunities for negativism. The child will continue trying to assert control. The toddler is
too young for verbal explanations. The negativism is the child testing limits. These should be
clearly defined by structured choices.
DIF: Cognitive Level: Understand
REF: p. 364
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
19. The parents of a 2-year-old tell the nurse that they are concerned because the toddler has
started to use “baby talk” since the arrival of their new baby. The nurse should recommend
which intervention?
a. Ignore the “baby talk.”
b. Explain to the toddler that “baby talk” is for babies.
c. Tell the toddler frequently, “You are a big kid now.”
d. Encourage the toddler to practice more advanced patterns of speech.
ANS: A
The baby talk is a sign of regression in the toddler. It should be ignored, while praising the
child for developmentally appropriate behaviors. Regression is children’s way of expressing
stress. The parents should not introduce new expectations and allow the child to master the
developmental tasks without criticism.
DIF: Cognitive Level: Apply
REF: p. 364
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table
with the family briefly, and wants snacks “all the time.” Which intervention should the nurse
recommend?
a. Give her nutritious snacks.
b. Offer rewards for eating at mealtimes.
c. Avoid snacks so she is hungry at mealtimes.
d. Explain to her in a firm manner what is expected of her.
ANS: A
Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional
requirement associated with the slower growth rate. Parents should help the child develop
healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious
snacks are a good way to ensure proper nutrition. To help with developing healthy eating
habits, food should be not be used as positive or negative reinforcement for behavior. The
child may develop habits of overeating or eat nonnutritious foods in response.
DIF: Cognitive Level: Apply
REF: p. 366
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
21. A father tells the nurse that his daughter wants the same plate and cup used at every meal,
even if they go to a restaurant. What should the nurse explain to the father?
A sign the child is spoiled
A way to exert unhealthy control
Regression, common at this age
Ritualism, common at this age
a.
b.
c.
d.
ANS: D
The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to
maintain sameness and reliability. It provides a sense of comfort to the toddler. It will dictate
certain principles in feeding practices, including rejecting a favorite food because it is served
in a different container. Ritualism is not indicative of a child who has unreasonable
expectations, but rather normal development. Toddlers use ritualistic behaviors to maintain
necessary structure in their lives. This is not regression, which is a retreat from a present
pattern of functioning.
DIF: Cognitive Level: Apply
REF: p. 355
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
22. Developmentally, what should most children at age 12 months be able to do?
a.
b.
c.
d.
Use a spoon adeptly
Relinquish the bottle voluntarily
Eat the same food as the rest of the family
Reject all solid food in preference to the bottle
ANS: C
By age 12 months, most children are eating the same food that is prepared for the rest of the
family. Using a spoon usually is not mastered until age 18 months. The parents should be
engaged in weaning a child from a bottle if that is the source of liquid. Toddlers should be
encouraged to drink from a cup at the first birthday and be weaned from the bottle totally by
14 months. The child should be weaned from a milk- or formula-based diet to a balanced diet
that includes iron-rich sources of food.
DIF: Cognitive Level: Understand
REF: p. 361
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
23. What is the most effective way to clean a toddler’s teeth?
a. Child to brush regularly with a toothpaste of his or her choice
b. Parent to stabilize the chin with one hand and brush with the other
c. Parent to brush the mandibular occlusive surfaces, leaving the rest for the child
d. Parent to brush the front labial surfaces, leaving the rest for the child
ANS: B
For young children, the most effective cleaning of teeth is by the parents. Different positions
can be used if the child’s back is to the adult. The adult should use one hand to stabilize the
chin and the other to brush the child’s teeth. The child can participate in brushing, but for a
thorough cleaning, adult intervention is necessary.
DIF: Cognitive Level: Understand
REF: p. 368
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
24. Which is an appropriate recommendation for preventing tooth decay in young children?
a. Substitute raisins for candy.
b. Substitute sugarless gum for regular gum.
c. Use honey or molasses instead of refined sugar.
d. When sweets are to be eaten, select a time not during meals.
ANS: B
Regular gum has high sugar content. When the child chews gum, the sugar is in prolonged
contact with the teeth. Sugarless gum is less cariogenic than regular gum. Raisins, honey, and
molasses are highly cariogenic and should be avoided. Sweets should be consumed with
meals so that the teeth can be cleaned afterward. This decreases the amount of time that the
sugar is in contact with the teeth.
DIF: Cognitive Level: Analyze
REF: p. 368
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
25. Which is the leading cause of death during the toddler period?
a. Injuries
b. Infectious diseases
c. Congenital disorders
d. Childhood diseases
ANS: A
Injuries are the single most common cause of death in children ages 1 through 4 years. This
represents the highest rate of death from injuries of any childhood age group except
adolescence. Infectious diseases and childhood diseases are less common causes of deaths in
this age group. Congenital disorders are the second leading cause of death in this age group.
DIF: Cognitive Level: Understand
REF: p. 370
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
26. Kimberly’s parents have been using a rearward-facing, convertible car seat since she was
born. Most car seats can be safely switched to the forward-facing position when the child
reaches which age?
a. 1
b. 2
c. 3
d. 4
ANS: B
It is now recommended that all infants and toddlers ride in rear-facing car safety seats until
they reach the age of 2 years or height recommended by the car seat manufacturer. Children 2
years old and older who have outgrown the rear-facing height or weight limit for their car
safety seat should use a forward-facing car safety seat with a harness up to the maximum
height or weight recommended by the manufacturer. One year is too young to switch to a
forward-facing position.
DIF: Cognitive Level: Understand
REF: p. 372
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
27. The nurse recommends to parents that peanuts are not a good snack food for toddlers. What is
the nurse’s rationale for this action?
a. Low in nutritive value
b. High in sodium
c. Cannot be entirely digested
d. Can be easily aspirated
ANS: D
Foreign-body aspiration is common during the second year of life. Although they chew well,
this age child may have difficulty with large pieces of food, such as meat and whole hot dogs,
and with hard foods, such as nuts or dried beans. Peanuts have many beneficial nutrients, but
should be avoided because of the risk of aspiration in this age group. The sodium level may
be a concern, but the risk of aspiration is more important. Many foods pass through the
gastrointestinal tract incompletely undigested. This is not necessarily detrimental to the child.
DIF: Cognitive Level: Apply
REF: p. 376
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
28. The parent of a 16-month-old toddler asks, “What is the best way to keep our son from
getting into our medicines at home?” The nurse’s best advice is:
“All medicines should be locked securely away.”
“The medicines should be placed in high cabinets.”
“The child just needs to be taught not to touch medicines.”
“Medicines should not be kept in the homes of small children.”
a.
b.
c.
d.
ANS: A
The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch
cabinets, and obtain access to high-security places. For medications, only a locked cabinet is
safe. Toddlers can climb by using furniture. High places are not a deterrent to an exploring
toddler. Toddlers are not able to generalize as dangerous all the different forms of
medications that may be available in the home. It is not feasible to not keep medicines in the
homes of small children. Many parents require medications for chronic illnesses. Parents
must be taught safe storage for their home and when they visit other homes.
DIF: Cognitive Level: Apply
REF: p. 376
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
29. What is the most fatal type of burn in the toddler age group?
a. Flame burn from playing with matches
b. Scald burn from high-temperature tap water
c. Hot object burn from cigarettes or irons
d. Electric burn from electric outlets
ANS: A
Flame burns from matches and lighters represent one of the most fatal types of burns in the
toddler age group. High-temperature tap water, hot objects, and electrical outlets are all
significant causes of burn injury. The child should be protected from these causes by reducing
the temperature on the hot water in the home, keeping objects such as cigarettes and irons
away from children, and placing protective guards over electric outlets when not in use.
DIF: Cognitive Level: Understand
REF: p. 375
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment
30. Which play item should the nurse bring from the playroom to a hospitalized toddler in
isolation?
Small plastic Lego
Set of large plastic building blocks
Brightly colored balloon
Coloring book and crayons
a.
b.
c.
d.
ANS: B
Play objects for toddlers must still be chosen with an awareness of danger from small parts.
Large, sturdy toys without sharp edges or removable parts are safest. Large plastic blocks are
appropriate for a toddler in isolation. Small plastic toys such as Lego can cause choking or
can be aspirated. Balloons can cause significant harm if swallowed or aspirated. Coloring
book and crayons would be too advanced for a toddler.
DIF: Cognitive Level: Apply
REF: p. 355
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment
31. A nurse places some x-ray contrast the toddler is to drink in a small cup instead of a large
cup. Which concept of a toddler’s preoperational thinking is the nurse using?
a. Inability to conserve
b. Magical thinking
c. Centration
d. Irreversibility
ANS: A
The nurse is using the toddler’s inability to conserve. This is when the toddler is unable to
understand the idea that a mass can be changed in size, shape, volume, or length without
losing or adding to the original mass. Instead, toddlers judge what they see by the immediate
perceptual clues given to them. A small glass means less amount of contrast. Magical
thinking is believing that thoughts are all-powerful and can cause events. Centration is
focusing on one aspect rather than considering all possible alternatives. Irreversibility is the
inability to undo or reverse the actions initiated, such as being unable to stop doing an action
when told.
DIF: Cognitive Level: Apply
REF: p. 357
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
32. Parents need further teaching about the use of car safety seats if they make which statement?
a. “Even if our toddler helps buckle the straps, we will double-check the fastenings.”
b. “We won’t start the car until everyone is properly restrained.”
c. “We won’t need to use the car seat on short trips to the store.”
d. “We will anchor the car seat to the car’s anchoring system.”
ANS: C
Parents need to be taught to always use the restraint even for short trips. Further teaching is
needed if they make this statement. Parents have understood the teaching if they encourage
the child to help attach buckles, straps, and shields but always double-check fastenings; do
not start the car until everyone is properly restrained; and anchor the car safety seat securely
to the car’s anchoring system and apply the harness snugly to the child.
DIF: Cognitive Level: Apply
REF: p. 373
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
33. The nurse is teaching parents of toddlers about animal safety. Which should be included in
the teaching session?
a.
b.
c.
d.
Petting dogs in the neighborhood should be encouraged to prevent fear of dogs.
The toddler is safe to approach an animal if the animal is chained.
It is permissible for your toddler to feed treats to a dog.
Teach your toddler not to disturb an animal that is eating.
ANS: D
Parents should be taught that toddlers should not disturb an animal that is eating, sleeping, or
caring for young puppies or kittens. The child should avoid all strange animals and not be
encouraged to pet dogs in the neighborhood. The child should never approach a strange dog
that is confined or restrained. The inexperienced child should not feed a dog (if the child pulls
back when the animal moves to take the food, this can frighten and startle the animal).
DIF: Cognitive Level: Apply
REF: p. 377
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. Which are characteristic of physical development of a 30-month-old child? (Select all that
apply.)
Birth weight has doubled.
Primary dentition is complete.
Sphincter control is achieved.
Anterior fontanel is open.
Length from birth is doubled.
Left- or right-handedness is established.
a.
b.
c.
d.
e.
f.
ANS: B, C
Usually by age 30 months, the primary dentition of 20 teeth is completed, and the child has
sphincter control in preparation for bowel and bladder control. Birth weight doubles at
approximately ages 5 to 6 months. The anterior fontanel closes at age 12 to 18 months. Birth
length is doubled around age 4. Left- or right-handedness is not established until about age 5.
DIF: Cognitive Level: Understand
REF: p. 361
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which should the nurse teach to parents of toddlers about accidental poison prevention?
(Select all that apply.)
Keep toxic substances in the garage.
Discard empty poison containers.
Know the number of the nearest poison control center.
Remove colorful labels from containers of toxic substances.
Caution child against eating nonedible items, such as plants.
a.
b.
c.
d.
e.
ANS: B, C, E
To prevent accidental poisoning, parents should be taught to promptly discard empty poison
containers, know the number of the nearest poison control center, and to caution the child
against eating nonedible items, such as plants. Parents should place all potentially toxic
agents, including cosmetics, personal care items, cleaning products, pesticides, and
medications in a locked cabinet, not in the garage. Parents should be taught to never remove
labels from containers of toxic substances.
DIF: Cognitive Level: Apply
REF: p. 371
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which gross motor milestones should the nurse assess in an 18-month-old child? (Select all
that apply.)
Jumps in place with both feet
Takes a few steps on tiptoe
Throws ball overhand without falling
Pulls and pushes toys
Stands on one foot momentarily
a.
b.
c.
d.
e.
ANS: A, C, D
An 18-month-old child can jump in place with both feet, throw a ball overhand without
falling, and pull and push toys. Taking a few steps on tiptoe and standing on one foot
momentarily is not acquired until 30 months of age.
DIF: Cognitive Level: Understand
REF: p. 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 12: Health Promotion of the Preschooler and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which should the nurse expect of a healthy 3-year-old child?
a.
Jump rope
b.
Ride a two-wheel bicycle
c.
Skip on alternate feet
d.
Balance on one foot for a few seconds
ANS: D
Three-year-olds are able to accomplish this gross motor skill. Jumping rope, riding a two-wheel
bicycle, and skipping on alternate feet are gross motor skills of 5-year-olds.
DIF: Cognitive Level: Understand
REF: p. 391
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. In terms of fine motor development, which should the 3-year-old child be expected to do?
a.
Lace shoes and tie shoelaces with a bow.
b.
Use scissors to cut pictures, and print a few
c.
d.
numbers.
Draw a person with seven parts and correctly
identify the parts.
Draw a circle and name what has been drawn.
ANS: D
Three-year-olds are able to accomplish this fine motor skill. Being able to lace shoes and tie
shoelaces with a bow, use scissors to cut pictures, and print a few numbers, or draw a person with
seven parts and correctly identify the parts are fine motor skills of 4- or 5-year-olds.
DIF: Cognitive Level: Understand
REF: p. 380
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is assessing a preschool-age child and notes the child exhibits magical thinking. Accord-
ing to Piaget, which describes magical thinking?
Events have cause and effect.
God is like an imaginary friend.
Thoughts are all-powerful.
If the skin is broken, the child’s insides will
come out.
a.
b.
c.
d.
ANS: C
Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are
all-powerful. Cause-and-effect implies logical thought, not magical thinking. Thinking God is
like an imaginary friend is an example of concrete thinking in a preschooler’s spiritual development. Thinking that if the skin is broken, the child’s insides will come out is an example of concrete thinking in development of body image.
DIF: Cognitive Level: Apply
REF: p. 381
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse, instructing parents of a hospitalized preschool child, explains that which is descriptive
of the preschooler’s understanding of time?
a.
b.
c.
d.
Has no understanding of time
Associates time with events
Can tell time on a clock
Uses terms like “yesterday” appropriately
ANS: B
In a preschooler’s understanding, time has a relation with events such as “We’ll go outside after
lunch.” Preschoolers develop an abstract sense of time at age 3 years. Children can tell time on a
clock at age 7 years. Children do not fully understand use of time-oriented words until age 6
years.
DIF: Cognitive Level: Understand
REF: p. 385
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The nurse is caring for a hospitalized 4-year-old boy. His parents tell the nurse that they will be
back to visit at 6 PM. When the child asks the nurse when his parents are coming, the nurse’s
best response is
a.
“They will be here soon.”
b.
“They will come after dinner.”
c.
“Let me show you on the clock when 6 PM
is.”
d.
“I will tell you every time I see you how
much longer it will be.”
ANS: B
A 4-year-old child understands time in relation to events such as meals. Children perceive “soon”
as a very short time. The nurse may lose the child’s trust if his parents do not return in the time
he perceives as “soon.” Children cannot read or use a clock for practical purposes until age 7
years. I will tell you every time I see you how much longer it will be assumes the child understands the concepts of hours and minutes, which are not developed until age 5 or 6 years.
DIF: Cognitive Level: Apply
REF: p. 385
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A 4-year-old child is hospitalized with a serious bacterial infection. The child tells the nurse that
he is sick because he was “bad.” Which is the nurse’s best interpretation of this comment?
a.
Sign of stress
b.
Common at this age
c.
Suggestive of maladaptation
d.
Suggestive of excessive discipline at home
ANS: B
Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them
think they are directly responsible for events, making them feel guilty for things outside their
control. Children of this age show stress by regressing developmentally or acting out. Maladaptation is unlikely. Telling the nurse that he is sick because he was “bad” does not imply excessive
discipline at home.
DIF: Cognitive Level: Analyze
REF: p. 385
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. A 4-year-old child tells the nurse that she does not want another blood sample drawn because “I
need all my insides, and I don’t want anyone taking them out.” Which is the nurse’s best interpretation of this?
a.
Child is being overly dramatic.
b.
Child has a disturbed body image.
c.
Preschoolers have poorly defined body
d.
boundaries.
Preschoolers normally have a good understanding of their bodies.
ANS: C
Preschoolers have little understanding of body boundaries, which leads to fears of mutilation.
The child is not capable of being dramatic at 4 years of age. She truly has fear. Body image is
just developing in the school-age child. Preschoolers do not have good understanding of their
bodies.
DIF: Cognitive Level: Apply
REF: p. 388
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which play is most typical of the preschool period?
a.
Solitary
b.
Parallel
c.
Associative
d.
Team
ANS: C
Associative play is group play in similar or identical activities but without rigid organization or
rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children play in
teams.
DIF: Cognitive Level: Understand
REF: p. 383
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Why are imaginary playmates beneficial to the preschool child?
a.
Take the place of social interactions
b.
Take the place of pets and other toys
c.
Become friends in times of loneliness
d.
Accomplish what the child has already suc-
cessfully accomplished
ANS: C
One purpose of an imaginary friend is to be a friend in time of loneliness. Imaginary friends do
not take the place of social interaction, but may encourage conversation. Imaginary friends do
not take the place of pets or toys. Imaginary friends accomplish what the child is still attempting.
DIF: Cognitive Level: Understand
REF: p. 384
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Which characteristic best describes the language of a 3-year-old child?
a.
Asks meanings of words
b.
Follows directional commands
c.
Describes an object according to its composi
d.
tion
Talks incessantly regardless of whether anyone is listening
ANS: D
Because of the dramatic vocabulary increase at this age, 3-year-olds are known to talk incessantly regardless of whether anyone is listening. A 4- to 5-year-old asks lots of questions and can
follow simple directional commands. A 6-year-old can describe an object according to its composition.
DIF: Cognitive Level: Understand
REF: p. 385
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. By which age should the nurse expect that most children could obey prepositional phrases such
as “under,” “on top of,” “beside,” and “behind”?
18 months
24 months
3 years
4 years
a.
b.
c.
d.
ANS: D
At 4 years, children can understand directional phrases. Children at 18 months, 24 months, and 3
years are too young.
DIF: Cognitive Level: Understand
REF: p. 385
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. Which is a useful skill that the nurse should expect a 5-year-old child to be able to master?
a.
Tie shoelaces
b.
Use knife to cut meat
c.
Hammer a nail
d.
Make change out of a quarter
ANS: A
Tying shoelaces is a fine motor task of 5-year-olds. Using a knife to cut meat is a fine motor task
of a 7-year-old. Hammering a nail and making change out of a quarter are fine motor and cognitive tasks of an 8- to 9-year-old.
DIF: Cognitive Level: Understand
REF: p. 386
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. The nurse is guiding parents in selecting a daycare facility for their child. Which is especially im-
portant to consider when making the selection?
a.
Structured learning environment
b.
Socioeconomic status of children
c.
Cultural similarities of children
d.
Teachers knowledgeable about development
ANS: D
A teacher knowledgeable about development will structure activities for learning. A structured
learning environment is not necessary at this age. Socioeconomic status is not the most important
factor in selecting a preschool. Preschool is about expanding experiences with others, so cultural
similarities are not necessary.
DIF: Cognitive Level: Apply
REF: p. 384
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. Parents tell the nurse that they found their 3-year-old daughter and a male cousin of the same age
inspecting each other closely as they used the bathroom. Which is the most appropriate recommendation the nurse should make?
a.
Punish children so this behavior stops.
b.
Neither condone nor condemn the curiosity.
c.
Allow children unrestricted permission to sat
isfy this curiosity.
d.
Get counseling for this unusual and dangerous behavior.
ANS: B
Three-year-olds become aware of anatomic differences and are concerned about how the other
“works.” Such exploration should not be condoned or condemned. Children should not be punished for this normal exploration. Encouraging the children to ask questions of the parents and
redirecting their activity are more appropriate than giving permission. Exploration is age-appropriate and not dangerous behavior.
DIF: Cognitive Level: Apply
REF: p. 387
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
15. The parent of a 4-year-old boy tells the nurse that the child believes that monsters and boogey-
men are in his bedroom at night. What is the nurse’s best suggestion for coping with this problem?
a.
Let the child sleep with his parents.
b.
Keep a night-light on in the child’s bedroom.
c.
Help the child understand that these fears are
illogical.
d.
Tell the child frequently that monsters and
boogeymen do not exist.
ANS: B
A night-light shows a child that imaginary creatures do not lurk in the darkness. Letting the child
sleep with parents will not get rid of the fears. A 4-year-old child is in the preconceptual age and
cannot understand logical thought.
DIF: Cognitive Level: Apply
REF: p. 388
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. Preschoolers’ fears can best be dealt with by which intervention?
a.
Actively involving them in finding practical
b.
c.
d.
methods to deal with the frightening experience
Forcing them to confront the frightening object or experience in the presence of their par
ents
Using logical persuasion to explain away
their fears and help them recognize how unre
alistic the fears are
Ridiculing their fears so that they understand
that there is no need to be afraid
ANS: A
Actively involving them in finding practical methods to deal with the frightening experience is
the best way to deal with fears. Forcing a child to confront fears may make the child more afraid.
Preconceptual thought prevents logical understanding. Ridiculing fears does not make them go
away.
DIF: Cognitive Level: Apply
REF: p. 388
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Which accurately describes the speech of the preschool child?
a.
Dysfluency in speech patterns is normal.
b.
Sentence structure and grammatic usage are
c.
d.
limited.
By age 5 years, child can be expected to have
a vocabulary of about 1000 words.
Rate of vocabulary acquisition keeps pace
with the degree of comprehension of speech.
ANS: A
Dysfluency includes stuttering and stammering, a normal characteristic of language development. Children speak in sentences of three or four words at age 3 to 4 years and eight words by
age 5 years. At 5 years, children have a vocabulary of 2100 words. Children often gain vocabulary beyond degree of comprehension.
DIF: Cognitive Level: Understand
REF: p. 389
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
18. A nurse is teaching parents about language development for preschool children. Which dysfunc-
tional speech pattern is a normal characteristic the parents might expect?
a.
Lisp
b.
Stammering
c.
d.
Echolalia
Repetition without meaning
ANS: B
Stammering and stuttering are normal dysfluency patterns in preschool-age children. Lisps are
not a normal characteristic of language development. Echolalia and repetition are traits of toddlers’ language.
DIF: Cognitive Level: Apply
REF: p. 389
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
19. What should injury prevention efforts emphasize during the preschool period?
a.
Constant vigilance and protection
b.
Punishment for unsafe behaviors
c.
Education for safety and potential hazards
d.
Limitation of physical activities
ANS: C
Education for safety and potential hazards is appropriate for preschoolers because they can begin
to understand dangers. Constant vigilance and protection is not practical at this age because
preschoolers are becoming more independent. Punishment may make children scared of trying
new things. Limitation of physical activities is not appropriate.
DIF: Cognitive Level: Understand
REF: p. 390
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment
20. Parents are concerned that their child is showing aggressive behaviors. Which suggestion should
the nurse make to the parents?
a.
b.
c.
d.
Supervise television viewing.
Ignore the behavior.
Punish the child for the behavior.
Accept the behavior if the child is male.
ANS: A
Television is also a significant source for modeling at this impressionable age. Research indicates
there is a direct correlation between media exposure, both violent and educational media, and
preschoolers exhibiting physical and relational aggression (Ostrov, Gentile, and Crick, 2006).
Therefore, parents should be encouraged to supervise television viewing. The behavior should
not be ignored because it can escalate to hyperaggression. The child should not be punished because it may reinforce the behavior if the child is seeking attention. For example, children who
are ignored by a parent until they hit a sibling or the parent learn that this act garners attention.
The behavior should not be accepted from a male child; this is using a “double standard” and aggression should not be equated with masculinity.
DIF: Cognitive Level: Apply
REF: p. 383
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
21. Which snack should the nurse recommend parents offer to their slightly overweight preschool
child?
a.
b.
c.
d.
Carbonated beverage
10% fruit juice
Low fat chocolate milk
Whole milk
ANS: C
Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Low-fat milk
may be substituted, so the quantity of milk may remain the same while limiting fat intake overall.
Parents should be educated regarding non-nutritious fruit drinks, which usually contain less than
10% fruit juice yet are often advertised as healthy and nutritious; sugar content is dramatically
increased and often precludes an adequate intake of milk by the child. In young children, intake
of carbonated beverages that are acidic or that contain high amounts of sugar is also known to
contribute to dental caries. Low fat milk should be substituted for whole milk if the child is
slightly overweight.
DIF: Cognitive Level: Apply
REF: p. 389
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. In terms of language and cognitive development, a 4-year-old child would be expected to have
which traits? (Select all that apply.)
a.
b.
c.
d.
e.
f.
Think in abstract terms.
Follow directional commands.
Understand conservation of matter.
Use sentences of eight words.
Tell exaggerated stories.
Comprehend another person’s perspective.
ANS: B, E
Children ages 3 to 4 years can give and follow simple commands and tell exaggerated stories.
Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of
the school-age child. Five-year-old children use sentences with eight words with all parts of
speech. A 4-year-old child cannot comprehend another’s perspective.
DIF: Cognitive Level: Apply
REF: p. 383
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which toys should a nurse provide to promote imaginative play for a 3-year-old hospitalized
child? (Select all that apply.)
a.
b.
c.
Plastic telephone
Hand puppets
Jigsaw puzzle (100 pieces)
d.
e.
Farm animals and equipment
Jump rope
ANS: A, B, D
To promote imaginative play for a 3-year-old child, the nurse should provide: dress-up clothes,
dolls, housekeeping toys, dollhouses, play-store toys, telephones, farm animals and equipment,
village sets, trains, trucks, cars, planes, hand puppets, or medical kits. A 100-piece jigsaw puzzle
and a jump rope would be appropriate for a young, school-age child but not a 3-year-old child.
DIF: Cognitive Level: Apply
REF: p. 383
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
COMPLETION
1. The recommendation for calcium for children 1 to 3 years of age is _____ milligrams. (Record
your answer in a whole number.)
ANS:
500
While limiting fat consumption, it is important to ensure diets contain adequate nutrients such as
calcium. The recommendation for daily calcium intake for children 1 to 3 years of age is 500 mg,
and the recommendation for children 4 to 8 years of age is 800 mg.
DIF: Cognitive Level: Remember
REF: p. 389
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 13: Health Problems of Toddlers and Preschoolers
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse suspects that a child has ingested some type of poison. Which clinical manifestation
would be most suggestive that the poison was a corrosive product?
a.
Tinnitus
b.
Disorientation
c.
Stupor, lethargy, coma
d.
Edema of lips, tongue, pharynx
ANS: D
Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system (CNS).
DIF: Cognitive Level: Analyze
REF: p. 394
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency de-
partment. The nurse taking the call should know that the primary danger is which result?
Hepatic dysfunction
Dehydration secondary to vomiting
Esophageal stricture and shock
Bronchitis and chemical pneumonia
a.
b.
c.
d.
ANS: D
Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not
hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal
stricture is a late or chronic issue of hydrocarbon ingestion.
DIF: Cognitive Level: Apply
REF: p. 411
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity
3. Which is a clinical manifestation of acetaminophen poisoning?
a.
Hyperpyrexia
b.
Hepatic involvement
c.
Severe burning pain in stomach
d.
Drooling and inability to clear secretions
ANS: B
Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does
not cause burning pain in stomach or pose an airway threat.
DIF: Cognitive Level: Understand
REF: p. 411
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. What is the result of acute salicylate (ASA, aspirin) poisoning?
a.
Chemical pneumonitis
b.
Hepatic damage
c.
Retractions and grunting
d.
Disorientation and loss of consciousness
ANS: D
ASA poisoning causes disorientation and loss of consciousness. Chemical pneumonitis is caused
by hydrocarbon ingestion. Hepatic damage is caused by acetaminophen overdose. ASA does not
cause airway obstruction.
DIF: Cognitive Level: Understand
REF: p. 412
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
5. A young child has just arrived at the emergency department after ingestion of aspirin at home.
The practitioner has ordered activated charcoal. The nurse administers charcoal in which way?
a.
b.
c.
d.
Administer through a nasogastric tube because the child will not drink it because of the
taste.
Serve in a clear plastic cup so the child can
see how much has been drunk.
Give half of the solution, and then give the
other half in 1 hour.
Serve in an opaque container with a straw.
ANS: D
Although the activated charcoal can be mixed with a flavorful beverage, it will be black and resemble mud. When it is served in an opaque container, the child does not have any preconceived
ideas about its being distasteful. The nasogastric tube should be used only in children without a
gag reflex. The ability to see the charcoal solution may affect the child’s desire to drink it. The
child should be encouraged to drink the solution all at once.
DIF: Cognitive Level: Apply
REF: p. 412
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
6. Which is the most frequent source of acute childhood lead poisoning?
a.
Folk remedies
b.
Unglazed pottery
c.
Lead-based paint
d.
Cigarette butts and ashes
ANS: C
Lead-based paint in houses built before 1978 is the most frequent source of lead poisoning. Some
folk remedies and unglazed pottery may contain lead, but they are not the most frequent source.
Cigarette butts and ashes do not contain lead.
DIF: Cognitive Level: Understand
REF: p. 414
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
7. At what blood level is chelation therapy for lead poisoning initiated in a child?
a.
10 to 14 g/dl
b.
15 to 19 g/dl
c.
20 to 44 g/dl
d.
≥45 g/dl
ANS: D
Chelation therapy is initiated if the child’s blood level is greater than or equal to 45 g/dl. At 10 to
14 g/dl, the family should have lead-poisoning education and follow-up level. At 15 to 19 g/dl,
the family should have lead-poisoning education and follow-up level but if it persists, initiate environmental investigation. At 20 to 44 g/dl environmental investigation and lead hazard control
are necessary.
DIF: Cognitive Level: Apply
REF: p. 415
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
8. Which describes a child who is abused by the parent(s)?
a.
Unintentionally contributes to the abusing sit
b.
c.
d.
uation
Belongs to a low socioeconomic population
Is healthier than the nonabused siblings
Abuses siblings in the same way as child is
abused by the parent(s)
ANS: A
Child’s temperament, position in the family, additional physical needs, activity level, or degree of
sensitivity to parental needs unintentionally contribute to the abusing situation. Abuse occurs
among all socioeconomic levels. Children who are ill or have additional physical needs are more
likely to be abused. The abused child may not abuse siblings.
DIF: Cognitive Level: Understand
REF: p. 418
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
9. Which is a common characteristic of those who sexually abuse children?
a.
Pressure victim into secrecy
b.
Are usually unemployed and unmarried
c.
Are unknown to victims and victims’ families
d.
Have many victims that are each abused once
only
ANS: A
Sex offenders may pressure the victim into secrecy regarding the activity as a “secret between
us” that other people may take away if they find out. The offender may be anyone, including
family members and persons from any level of society. Sex offenders are usually trusted acquaintances of the victims and victims’ families. Many victims are abused many times over a long period.
DIF: Cognitive Level: Understand
REF: p. 422
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
10. A 3-month-old infant dies shortly after arrival to the emergency department. The infant has sub-
dural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect?
Unintentional injury
Shaken-baby syndrome
Sudden infant death syndrome (SIDS)
Congenital neurologic problem
a.
b.
c.
d.
ANS: B
Shaken-baby syndrome causes internal bleeding but may have no external signs. Unintentional
injury would not cause these injuries. SIDS and congenital neurologic problems would not ap-
pear this way.
DIF: Cognitive Level: Analyze
REF: p. 419
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
11. Which is probably the most important criterion on which to base the decision to report suspected
child abuse?
a.
b.
c.
d.
Inappropriate parental concern for the degree
of injury
Absence of parents for questioning about
child’s injuries
Inappropriate response of child
Incompatibility between the history and injury observed
ANS: D
Conflicting stories about the “accident” are the most indicative red flags of abuse. Inappropriate
response of caregiver or child may be present, but is subjective. Parents should be questioned at
some point during the investigation.
DIF: Cognitive Level: Apply
REF: p. 419
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
12. A nurse is beginning chelation therapy on a child for lead poisoning. Which intervention should
the nurse implement during the time the child is receiving chelation therapy?
Calorie counts
Strict intake and output
Telemetry monitoring
Contact isolation
a.
b.
c.
d.
ANS: B
Because calcium disodium edetate (EDTA) and lead are toxic to the kidneys, a nurse should keep
strict records of intake and output to monitor renal functioning. Adequate hydration is essential
during therapy because the chelates are excreted via the kidneys. Calorie counts, telemetry, or
contact isolation would not be nursing interventions appropriate for a child undergoing chelation
therapy.
DIF: Cognitive Level: Apply
REF: p. 417
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
13. A child has been admitted to the emergency department with an acetaminophen (Tylenol) poison-
ing. An antidote is being prescribed by the health care provider. Which antidote should the nurse
prepare to administer?
a.
Naloxone (Narcan)
b.
N-acetylcysteine (Mucomyst)
c.
Flumazenil (Romazicon)
d.
Digoxin immune Fab (Digibind)
ANS: B
Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen poisoning, naloxone for opioid overdose, flumazenil (Romazicon) for benzodiazepine (diazepam [Valium], midazolam [Versed]) overdose, and digoxin immune Fab (Digibind) for digoxin toxicity.
DIF: Cognitive Level: Apply
REF: p. 409
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
14. The home health nurse is planning care for a 3-year-old boy who has Down syndrome and is re-
ceiving continuous oxygen. He recently began walking around furniture. He is spoon-fed by his
parents and eats some finger foods. Which is the most appropriate goal to promote normal development?
a.
Encourage mobility.
b.
Encourage assistance in self-care.
c.
Promote oral-motor development.
d.
Provide opportunities for socialization.
ANS: A
A major principle for developmental support in children with complex medical issues is that it
should be flexible and tailored to the individual child’s abilities, interests, and needs. This child
is exhibiting readiness for ambulation. It is an appropriate time to provide activities that encourage mobility, for example, longer oxygen tubing. Parents should provide decreasing amounts of
assistance with self-care as he is able to develop these skills. He is receiving oral foods and is
eating finger foods. He has acquired oral-motor development. Mobility is a new developmental
task. Opportunities for socialization should be ongoing.
DIF: Cognitive Level: Apply
REF: p. 403
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is teaching parents methods to reduce lead levels in their home. Which should the nurse
include in the teaching? (Select all that apply.)
a.
Plant bushes around the outside of the house.
b.
Ensure your child eats frequent meals.
c.
Use hot water from the tap when boiling veg
etables.
d.
Food can be stored in ceramic in the refriger
ator.
e.
Ensure that your child’s diet contains sufficient iron and calcium.
ANS: A, B, E
Methods to reduce lead levels in homes include: planting bushes around the outside of the house
if soil is contaminated with lead, so children cannot play there; ensuring that children eat regular
meals because more lead is absorbed on an empty stomach; and ensuring that children’s diets
contain sufficient iron and calcium. Cold water should only be used for drinking, cooking, and
reconstituting powder infant formula. Hot water dissolves lead more quickly than cold water and
thus contains higher levels of lead. Do not use pottery or ceramic ware that was inadequately
fired or is meant for decorative use for food storage or service.
DIF: Cognitive Level: Apply
REF: p. 418
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the correct sequence for emergency treatment of poisoning in a child. Provide an-
swer using lowercase letters separated by commas (e.g., a, b, c, d).
a. Locate the poison.
b. Assess the child.
c. Prevent absorption of poison.
d. Terminate exposure to the toxic substance.
ANS:
b, d, a, c
The initial step in treating poisonings is to assess the child, treat immediate life-threatening conditions, and initiate cardiopulmonary resuscitation (CPR) if indicated. Terminating the exposure
to the toxic substance is the second step. Locating the poison for identification is the third step.
Preventing absorption of poison is the fourth step.
DIF: Cognitive Level: Apply
REF: p. 416
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 14: Health Promotion of the School-Age Child and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is teaching a group of 10- to 12-year-old children about physical development during
the school-age years. Which statement made by a participant, indicates the correct understanding
of the teaching?
a.
“My body weight will be almost triple in the
next few years.”
b.
“I will grow an average of 2 inches per year
from this point on.”
c.
“There are not that many physical differences
d.
among school-age children.”
“I will have a gradual increase in fat, which
may contribute to a heavier appearance.”
ANS: B
In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6
and 12 years, children grow 2 inches per year. In middle childhood, children’s weight will almost
double; they gain 3 kg/year. At the end of middle childhood, girls grow taller and gain more
weight than boys. Children take on a slimmer look with longer legs in middle childhood.
DIF: Cognitive Level: Apply
REF: p. 429
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. What is the earliest age at which puberty begins?
a.
9
b.
10
c.
11
d.
12
ANS: A
There is no universal age at which children assume the characteristics of prepubescence. The first
physiologic signs appear at about 9 years of age (particularly in girls) and are usually clearly evident in 11- to 12-year-old children.
DIF: Cognitive Level: Understand
REF: p. 430
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which describes the cognitive abilities of school-age children?
a.
Have developed the ability to reason abb.
c.
d.
stractly
Are capable of scientific reasoning and formal logic
Progress from making judgments based on
what they reason to making judgments based
on what they see
Are able to classify, to group and sort, and to
hold a concept in their minds while making
decisions based on that concept
ANS: D
In Piaget’s stage of concrete operations, children have the ability to group and sort and make
conceptual decisions. Children cannot reason abstractly and logically until late adolescence.
Making judgments based on what they reason to making judgments based on what they see is not
a developmental skill.
DIF: Cognitive Level: Understand
REF: p. 431
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which describes moral development in younger school-age children?
a.
The standards of behavior now come from
b.
c.
d.
within themselves.
They do not yet experience a sense of guilt
when they misbehave.
They know the rules and behaviors expected
of them but do not understand the reasons be
hind them.
They no longer interpret accidents and misfortunes as punishment for misdeeds.
ANS: C
Children who are ages 6 and 7 years know the rules and behaviors expected of them but do not
understand the reasons for these rules and behaviors. Young children do not believe that standards of behavior come from within themselves, but that rules are established and set down by
others. Younger school-age children learn standards for acceptable behavior, act according to
these standards, and feel guilty when they violate them. Misfortunes and accidents are viewed as
punishment for bad acts.
DIF: Cognitive Level: Understand
REF: p. 431
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which statement characterizes moral development in the older school-age child?
a.
They are able to judge an act by the intentions
b.
c.
d.
that prompted it rather than just by the conse
quences.
Rules and judgments become more absolute
and authoritarian.
They view rule violations in an isolated context.
They know the rules but cannot understand
the reasons behind them.
ANS: A
Older school-age children are able to judge an act by the intentions that prompted the behavior
rather than just by the consequences. Rules and judgments become less absolute and authoritarian. Rule violation is likely to be viewed in relation to the total context in which it appears. The
situation and the morality of the rule itself influence reactions.
DIF: Cognitive Level: Understand
REF: p. 431
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. An 8-year-old girl tells the nurse that she has cancer because God is punishing her for “being
bad.” She shares her concern that if she dies, she will go to hell. How should the nurse interpret
this statement?
a.
b.
c.
d.
A common belief at this age
A belief that forms the basis for most religions
Suggestive of excessive family pressure
Suggestive of a failure to develop a conscience
ANS: A
Children at this age may view illness or injury as a punishment for a real or imagined misdeed.
The belief in divine punishment is common for an 8-year-old child.
DIF: Cognitive Level: Analyze
REF: p. 432
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Parents ask the nurse whether it is common for their school-age child to spend a lot of time with
peers. The nurse should respond, explaining that the role of the peer group in the life of schoolage children provides:
a.
opportunity to become defiant.
b.
time to remain dependent on their parents for
a longer time.
c.
time to establish a one-on-one relationship
with the opposite sex.
d.
security as they gain independence from their
parents.
ANS: D
Peer-group identification is an important factor in gaining independence from parents. Children
learn how to relate to people in positions of leadership and authority and how to explore ideas
and the physical environment. Becoming defiant in a peer-group relationship may lead to bullying. Peer-group identification helps in gaining independence rather than remaining dependent.
One-on-one opposite sex relationships do not occur until adolescence. School-age children form
peer groups of the same sex.
DIF: Cognitive Level: Understand
REF: p. 433
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. A group of boys ages 9 and 10 years have formed a “boys-only” club that is open to neighbor-
hood and school friends who have skateboards. How should this be interpreted?
a.
Behavior that encourages bullying and sexism
b.
Behavior that reinforces poor peer relationships
c.
Characteristic of social development at this
age
d.
Characteristic of children who later are at risk
for membership in gangs
ANS: C
One of the outstanding characteristics of middle childhood is the creation of formalized groups
or clubs. Peer-group identification and association are essential to a child’s socialization. Poor relationships with peers and a lack of group identification can contribute to bullying. A boys-only
club does not have a direct correlation with later gang activity.
DIF: Cognitive Level: Analyze
REF: p. 433
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. A school nurse observes school-age children playing at recess. Which is descriptive of the play
the nurse expects to observe?
a.
b.
c.
d.
Individuality in play is better tolerated than at
earlier ages.
Knowing the rules of a game gives an impor
tant sense of belonging.
They like to invent games, making up the
rules as they go.
Team play helps children learn the universal
importance of competition and winning.
ANS: B
Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and
cliques and develop a sense of belonging to a team or club. At this age, children begin to see the
need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying
rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States.
DIF: Cognitive Level: Understand
REF: p. 437
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Bullying can be common during the school-age years. The nurse should recognize that which ap-
plies to bullying?
a.
b.
c.
d.
Can have a lasting effect on children
Is not a significant threat to self-concept
Is rarely based on anything that is concrete
Is usually ignored by the child who is being
bullied
ANS: A
Bullying in this age group is common and can have a long-lasting effect. Increasing awareness of
differences, especially when accompanied by unkind comments and taunts from others, may
make a child feel inferior and undesirable. Physical impairments such as hearing or visual defects, ears that “stick out,” or birth marks assume great importance.
DIF: Cognitive Level: Understand
REF: p. 439
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Which is characteristic of dishonest behavior in children ages 8 to 10 years?
a.
Cheating during games is now more common.
b.
Lying results from the inability to distinguish
c.
d.
between fact and fantasy.
They may steal because their sense of property rights is limited.
They may lie to meet expectations set by oth
ers that they have been unable to attain.
ANS: D
Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. In this age
group, children are able to distinguish between fact and fantasy. Young children may lack a sense
of property rights; older children may steal to supplement an inadequate allowance, or it may be
an indication of serious problems.
DIF: Cognitive Level: Understand
REF: p. 439
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says
she is completing her schoolwork satisfactorily but lately has been somewhat aggressive and
stubborn in the classroom. How should the nurse interpret this behavior?
a.
A sign of stress
b.
A developmental delay
c.
A physical problem
d.
A lack of adjustment to school
ANS: A
Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to early behaviors. This child is exhibiting signs of stress.
DIF: Cognitive Level: Apply
REF: p. 439
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. Which statement best describes fear in the school-age child?
a.
They are increasingly fearful for body safety.
b.
Most of the new fears that trouble them are
c.
d.
related to school and family.
They should be encouraged to hide their fears
to prevent ridicule by peers.
Those who have numerous fears need contin
uous protective behavior by parents to elimi
nate these fears.
ANS: B
During the school-age years, children experience a wide variety of fears, but new fears relate pre-
dominantly to school and family. During the middle-school years, children become less fearful
for body safety than they were as preschoolers. Parents and other persons involved with children
should discuss children’s fears with them individually or as a group activity. Sometimes schoolage children hide their fears to avoid being teased. Hiding their fears does not end them and may
lead to phobias.
DIF: Cognitive Level: Analyze
REF: p. 439
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
14. The father of a 12-year-old child tells the nurse that he is concerned about his son getting “fat.”
His son is at the 50th percentile for height and the 75th percentile for weight on the growth chart.
What is the most appropriate nursing action?
a.
Reassure the father that his child is not fat
b.
Reassure the father that his child is just grow
ing
c.
Suggest a low-calorie, low-fat diet
d.
Explain that this is typical of the growth pat
tern of boys at this age
ANS: D
This is a characteristic pattern of growth in preadolescent boys, where the growth in height has
slowed in preparation for the pubertal growth spurt, but weight is still gained. The nurse should
review this with both the father and the child and develop a plan to maintain physical exercise
and a balanced diet. It is false reassurance to tell the father that his son is not fat. His weight is
high for his height. The child needs to maintain his physical activity. The father is concerned, so
an explanation is required. A nutritional diet with physical activity should be sufficient to maintain his balance.
DIF: Cognitive Level: Apply
REF: p. 440
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A child has an evulsed (knocked-out) tooth. Which medium should the nurse instruct the parents
to place the tooth in for transport to the dentist?
a.
In cold milk
b.
In cold water
c.
In warm salt water
d.
In a dry, clean jar
ANS: A
An evulsed tooth should be placed in a suitable medium for transplant, either cold milk or saliva
(under the child or parent’s tongue). Cold milk is a more suitable medium for transport than cold
water, warm salt water, or a dry, clean jar.
DIF: Cognitive Level: Apply
REF: p. 441
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
16. The school nurse has been asked to begin teaching sex education in the fifth grade. What should
the nurse recognize about this age group?
a.
b.
c.
d.
Children in fifth grade are too young for sex
education.
Children should be discouraged from asking
too many questions.
Correct terminology should be reserved for
children who are older.
Sex can be presented as a normal part of
growth and development.
ANS: D
When sexual information is presented to school-age children, sex should be treated as a normal
part of growth and development. Fifth-graders are usually 10 or 11 years old. This age is not too
young to speak about physiologic changes in their bodies. They should be encouraged to ask
questions. Preadolescents need precise and concrete information.
DIF: Cognitive Level: Apply
REF: p. 445
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. The school nurse is conducting a class on bicycle safety. Which statement made by a participant
indicates a need for further teaching?
a.
b.
c.
d.
“Most bicycle injuries occur from a fall off
the bicycle.”
“Head injuries are the major causes of bicycle-related fatalities.”
“I should replace my helmet every 5 years.”
“I can ride double with a friend if the bicycle
has an extra-large seat.”
ANS: D
Children should not ride double. Most injuries result from falls. The most important aspect of bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major
cause of bicycle-related fatalities. The child should always wear a properly fitted helmet approved by the US Consumer Product Safety Commission and should replace the helmet at least
every 5 years.
DIF: Cognitive Level: Apply
REF: p. 445
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
18. When teaching injury prevention during the school-age years, what should the nurse include?
a.
Teach children to fear strangers.
b.
Teach basic rules of water safety.
c.
Avoid letting child cook in microwave ovens.
d.
Caution child against engaging in competitive
sports.
ANS: B
Water safety instruction is an important source of injury prevention at this age. The child should
be taught to swim, select safe and supervised places to swim, swim with a companion, check for
sufficient water depth before diving, and use an approved flotation device. Teach stranger safety,
not fear of strangers. This includes instructing children to not go with strangers, not wear personalized clothing in public places, tell parents if anyone makes child feel uncomfortable, and say
“no” in uncomfortable situations. Teach child safe cooking. Caution against engaging in hazardous sports such as those involving trampolines.
DIF: Cognitive Level: Apply
REF: p. 444
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
19. A nurse is teaching parents of kindergarten children general guidelines to assist their children in
school. Which statement by the parents indicates they understand the teaching?
a.
“We will only meet with the teacher if problems occur.”
b.
“We will discourage hobbies so our child fo
cuses on schoolwork.”
c.
“We will plan a trip to the library as often as
possible.”
d.
“We will expect our child to make all As in
school.”
ANS: C
General guidelines for parents to help their child in school include sharing an interest in reading.
The library should be used frequently, and books the child is reading should be discussed. Hobbies should be encouraged. The parents should not expect all As. They should focus on growth
more than grades.
DIF: Cognitive Level: Apply
REF: p. 438
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. A school nurse is teaching dental health practices to a group of sixth-grade children. How often
should the nurse recommend the children brush their teeth?
a.
Twice a day
b.
Three times a day
c.
After meals
d.
After meals, after snacks, and at bedtime
ANS: D
Teeth should be brushed after meals, after snacks, and at bedtime. Children who brush their teeth
frequently and become accustomed to the feel of a clean mouth at an early age usually maintain
the habit throughout life. Twice a day, three times a day, or after meals would not be often
enough.
DIF: Cognitive Level: Comprehend
REF: p. 441
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
21. Parents of a 12-year-old child ask the clinic nurse, “How many hours of sleep should our child
get?” The nurse should respond that 12-year-old children need how many hours of sleep at night?
8
9
10
11
a.
b.
c.
d.
ANS: B
School-age children usually do not require naps, but they do need to sleep approximately 11
hours at age 5 years and 9 hours at age 12 years each night.
DIF: Cognitive Level: Apply
REF: p. 440
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
22. A nurse planning care for a school-age child should take into account that which thought process
is seen at this age?
a.
b.
c.
d.
Animism
Magical thinking
Ability to conserve
Thoughts are all-powerful
ANS: C
One cognitive task of school-age children is mastering the concept of conservation. At an early
age (5 to 7 years), children grasp the concept of reversibility of numbers as a basis for simple
mathematics problems (e.g., 2 + 4 = 6 and 6 – 4 = 2). They learn that simply altering their arrangement in space does not change certain properties of the environment, and they are able to
resist perceptual cues that suggest alterations in the physical state of an object. Animism, magical
thinking, and believing that thoughts are all powerful are thought processes seen in preschool
children.
DIF: Cognitive Level: Apply
REF: p. 432
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
23. A school-age child falls on the playground and has a small laceration on the forearm. The school
nurse should do which to cleanse the wound?
Slowly pour hydrogen peroxide over wound.
Soak arm in warm water and soap for at least
30 minutes.
c.
Gently cleanse with sterile pad and a nonstinging povidone-iodine solution.
d.
Wash wound gently with mild soap and water
for several minutes.
a.
b.
ANS: D
Lacerations should be washed gently with mild soap and water or normal saline. A sterile pad is
not necessary, and hydrogen peroxide and povidone-iodine should not be used because they have
a cytotoxic effect on healthy cells and minimal effect on controlling infection. Soaking the arm
will not effectively clean the wound.
DIF: Cognitive Level: Apply
REF: p. 434
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A nurse is planning care for a 7-year-old child hospitalized with osteomyelitis. Which activities
should the nurse plan to bring from the playroom for the child? (Select all that apply.)
a.
Paper and some paints
b.
Board games
c.
Jack-in-the-box
d.
Stuffed animals
e.
Computer games
ANS: A, B, E
School-age children become fascinated with complex board, card, or computer games that they
can play alone, with a best friend, or with a group. They also enjoy sewing, cooking, carpentry,
gardening, and creative activities such as painting. Jack-in-the-box and stuffed animals would be
appropriate for a toddler or preschool child.
DIF: Cognitive Level: Apply
REF: p. 435
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse teaches parents that team play is important for school-age children. Which can children
develop by experiencing team play? (Select all that apply.)
a.
Achieve personal goals over group goals.
b.
Learn complex rules.
c.
Experience competition.
d.
Learn about division of labor.
ANS: B, C, D
Team play helps stimulate cognitive growth because children are called on to learn many complex rules, make judgments about those rules, plan strategies, and assess the strengths and weaknesses of members of their own team and members of the opposing team. Team play can also
contribute to children’s social, intellectual, and skill growth. Children work hard to develop the
skills needed to become team members, to improve their contribution to the group, and to anticipate the consequences of their behavior for the group. Team play teaches children to modify or
exchange personal goals for goals of the group; it also teaches them that division of labor is an
effective strategy for attaining a goal.
DIF: Cognitive Level: Apply
REF: p. 435
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 15: Health Promotion of the Adolescent and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. What is the initial indication of puberty in girls?
a.
Menarche
b.
Growth spurt
c.
Growth of pubic hair
d.
Breast development
ANS: D
In most girls, the initial indication of puberty is the appearance of breast buds, an event known as
thelarche. The usual sequence of secondary sex characteristic development in girls is breast
changes, rapid increase in height and weight, growth of pubic hair, appearance of axillary hair,
menstruation, and abrupt deceleration of linear growth.
DIF: Cognitive Level: Understand
REF: p. 448
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A school nurse is teaching a group of preadolescent girls about puberty. Which is the mean age of
menarche for girls in the United States?
a.
b.
c.
d.
years
years
years
14 years
ANS: B
The average age of menarche is 12 years 9.5 months in North American girls, with a normal
range of to 15 years. Ages , , and 14 are within the normal range for menarche, but these are not
the average ages.
DIF: Cognitive Level: Remember
REF: p. 448
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A school nurse is teaching a group of preadolescent boys about puberty. By which age should
concerns about pubertal delay be considered?
a.
12 years
b.
13 years
c.
14 years
d.
15 years
ANS: C
Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the
testes or scrotal changes from to 14 years. Ages 12 to years is too young for initial concern.
DIF: Cognitive Level: Remember
REF: p. 449
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A 14-year-old male mentions that he now has to use deodorant but never had to before. The
nurse’s response should be based on knowledge that which occurs during puberty?
a.
Eccrine sweat glands in the axillae become
fully functional during puberty.
b.
Sebaceous glands become extremely active
during puberty.
c.
New deposits of fatty tissue insulate the body
and cause increased sweat production.
d.
Apocrine sweat glands reach secretory capac
ity during puberty.
ANS: D
The apocrine sweat glands, nonfunctional in children, reach secretory capacity during puberty.
They secrete a thick substance as a result of emotional stimulation that, when acted on by surface
bacteria, becomes highly odoriferous. They are limited in distribution and grow in conjunction
with hair follicles, in the axilla, genital, anal, and other areas. Eccrine sweat glands are present
almost everywhere on the skin and become fully functional and respond to emotional and thermal stimulation. Sebaceous glands become extremely active at this time, especially those on the
genitalia and the “flush” areas of the body such as face, neck, shoulders, upper back, and chest.
This increased activity is important in the development of acne. New deposits of fatty tissue is
not the etiology of apocrine sweat gland activity.
DIF: Cognitive Level: Understand
REF: p. 449
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. According to Erikson, which psychosocial task is developing in adolescence?
a.
Intimacy
b.
Identity
c.
Initiative
d.
Independence
ANS: B
Traditional psychosocial theory holds that the developmental crises of adolescence lead to the
formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Independence is not one of Erikson’s developmental stages.
DIF: Cognitive Level: Understand
REF: p. 453
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A nurse is planning a teaching session for a group of adolescents. The nurse understands that by
adolescence the individual is in which stage of cognitive development?
a.
Formal operations
b.
c.
d.
Concrete operations
Conventional thought
Postconventional thought
ANS: A
Cognitive thinking culminates with capacity for abstract thinking. This stage, the period of formal operations, is Piaget’s fourth and last stage. Concrete operations usually occur between ages
7 and 11 years. Conventional and postconventional thought refers to Kohlberg’s stages of moral
development.
DIF: Cognitive Level: Understand
REF: p. 453
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which aspect of cognition develops during adolescence?
a.
Capability to use a future time perspective
b.
Ability to place things in a sensible and logi
c.
d.
cal order
Ability to see things from the point of view of
another
Progress from making judgments based on
what they see to making judgments based on
what they reason
ANS: A
Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years),
children exhibit these characteristic thought processes.
DIF: Cognitive Level: Remember
REF: p. 449
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Parents are concerned about the number of hours their teenage daughter spends with peers. The
nurse explains that peer relationships are important during adolescence for which reason?
a.
Adolescents dislike their parents.
b.
Adolescents no longer need parental control.
c.
They provide adolescents with a feeling of
belonging.
d.
They promote a sense of individuality in ado
lescents.
ANS: C
The peer group serves as a strong support to teenagers, providing them with a sense of belonging
and a sense of strength and power. During adolescence, the parent-child relationship changes
from one of protection-dependency to one of mutual affection and quality. Parents continue to
play an important role in the personal and health-related decisions. The peer group forms the
transitional world between dependence and autonomy.
DIF: Cognitive Level: Apply
REF: p. 449
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. An adolescent boy tells the nurse that he has recently had homosexual feelings. What knowledge
should the nurse’s response be based on?
a.
b.
c.
d.
This indicates the adolescent is homosexual.
This indicates the adolescent will become ho
mosexual as an adult.
The adolescent should be referred for psychotherapy.
The adolescent should be encouraged to share
his feelings and experiences.
ANS: D
These adolescents are at increased risk for health-damaging behaviors, not because of the sexual
behavior itself, but because of society’s reaction to the behavior. The nurse’s first priority is to
give the young man permission to discuss his feelings about this topic, knowing that the nurse
will maintain confidentiality, appreciate his feelings, and remain sensitive to his need to talk
about the topic. In recent studies among self-identified gay, lesbian, and bisexual adolescents,
many of the adolescents report changing self-labels one or more times during their adolescence.
An assessment must be made about any risks to himself or others. If these do not exist, the adolescent needs a supportive person to talk with.
DIF: Cognitive Level: Apply
REF: p. 449
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. The school nurse tells adolescents in the clinic that confidentiality and privacy will be main-
tained unless a life-threatening situation arises. How should this practice be interpreted?
a.
Not appropriate in a school setting
b.
Never appropriate because adolescents are
minors
c.
Important in establishing trusting relationships
d.
Suggestive that the nurse is meeting his or her
own needs
ANS: C
Health professionals who work with adolescents should consider adolescents’ increasing independence and responsibility while maintaining privacy and ensuring confidentiality. However, in
some circumstances, such as self-destructive behavior or maltreatment by others, they are not
able to maintain confidentiality. Confidentiality and privacy are necessary to build trust with this
age group. The nurse must be aware of the limits placed on confidentiality by local jurisdiction.
DIF: Cognitive Level: Understand
REF: p. 456
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Management of Care
11. A 14-year-old boy seems to be always eating, although his weight is appropriate for his height.
What is the best explanation for this?
a.
b.
c.
d.
This is normal because of increase in body
mass.
This is abnormal and suggestive of future
obesity.
His caloric intake would have to be excessive.
He is substituting food for unfilled needs.
ANS: A
In adolescence, nutritional needs are closely related to the increase in body mass. The peak requirements occur in the years of maximal growth. The caloric and protein requirements are
higher than at almost any other time of life. Seemingly always eating describes the expected eating pattern for young adolescents; as long as weight and height are appropriate, obesity is not a
concern.
DIF: Cognitive Level: Understand
REF: p. 459
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. Which predisposes the adolescent to feel an increased need for sleep?
a.
An inadequate diet
b.
Rapid physical growth
c.
Decreased activity that contributes to a feeld.
ing of fatigue
The lack of ambition typical of this age group
ANS: B
During growth spurts, the need for sleep increases. Rapid physical growth, the tendency toward
overexertion, and the overall increased activity of this age contribute to fatigue.
DIF: Cognitive Level: Understand
REF: p. 463
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. What is the most common cause of death in the adolescent age group?
a.
Drownings
b.
Firearms
c.
Drug overdoses
d.
Motor vehicles
ANS: D
Forty percent of all adolescent deaths in the United States are the result of motor vehicle accidents. Drownings, firearms, and drug overdoses are major concerns in adolescence but are not
the most common cause of death.
DIF: Cognitive Level: Understand
REF: p. 458
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
14. A young adolescent boy tells the nurse he “feels gawky.” How should the nurse explain why this
occurs in adolescents?
a.
b.
c.
d.
Growth of the extremities and neck precedes
growth in other areas
Growth is in the trunk and chest
The hip and chest breadth increases
The growth spurt occurs earlier in boys than it
does in girls
ANS: A
Growth in length of the extremities and neck precedes growth in other areas, and, because these
parts are the first to reach adult length, the hands and feet appear larger than normal during adolescence. Increases in hip and chest breadth take place in a few months followed several months
later by an increase in shoulder width. These changes are followed by increases in length of the
trunk and depth of the chest. This sequence of changes is responsible for the characteristic longlegged, gawky appearance of early adolescent children. The growth spurt occurs earlier in girls
than in boys.
DIF: Cognitive Level: Apply
REF: p. 450
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A nurse is reviewing hormone changes that occur during adolescence. What is the hormone re-
sponsible for the growth of beard, mustache, and body hair in the male?
a.
Estrogen
b.
Pituitary
c.
Androgen
d.
Progesterone
ANS: C
Beard, mustache, and body hair on the chest, upward along the linea alba, and sometimes on
other areas (e.g., back and shoulders) appears in males and is androgen dependent. Estrogen and
progesterone are produced by the ovaries in the female and do not contribute to body hair appearance in the male. The pituitary hormone does not have any relationship to body hair appearance in the male.
DIF: Cognitive Level: Analyze
REF: p. 448
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A nurse is caring for an adolescent hospitalized for cellulitis. The nurse notes that the adolescent
experiences many “mood swings” throughout the day. How should the nurse interpret this behavior?
a.
Requires a referral to a mental health counselor
b.
Requires some further lab testing
c.
It is normal behavior
d.
Related to feelings of depression
ANS: C
Adolescents vacillate in their emotional states between considerable maturity and childlike behavior. One minute they are exuberant and enthusiastic; the next minute they are depressed and
withdrawn. Because of these mood swings, adolescents are frequently labeled as unstable, inconsistent, and unpredictable, but the behavior is normal. The behavior would not require a referral
to a mental health counselor or further lab testing. The mood swings do not indicate depression.
DIF: Cognitive Level: Understand
REF: p. 449
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
17. A nurse is conducting parenting classes for parents of adolescents. Which parenting style should
the nurse recommend?
a.
b.
c.
d.
Laissez-faire
Authoritative
Disciplinarian
Confrontational
ANS: B
Parents should be guided toward an authoritative style of parenting in which authority is used to
guide the adolescent while allowing developmentally appropriate levels of freedom and providing clear, consistent messages regarding expectations. The authoritative style of parenting has
been shown to have both immediate and long-term protective effects toward adolescent risk reduction. The laissez-faire method would not give adolescents enough structure. The disciplinarian and confrontational styles would not allow any autonomy or independence.
DIF: Cognitive Level: Apply
REF: p. 456
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. A 14-year-old adolescent never had chickenpox as a child. What should the nurse expect the
health care provider to recommend?
a.
b.
c.
d.
One dose of the varicella vaccination
Two doses of the varicella vaccination 4
weeks apart
One dose of the varicella immune globulin
No vaccinations—the child is past the age to
receive it
ANS: B
All adolescents should also be assessed for previous history of varicella infection or vaccination.
Vaccination with the varicella vaccine is recommended for those with no previous history; for
those with no previous infection or history, the varicella vaccine may be given in two doses 4 or
more weeks apart to adolescents 13 years or older. The varicella immune globulin is given to immunosuppressed children exposed to chickenpox to boost immunity; it is only temporary. The
varicella vaccination should be given to adolescents, no matter the age, who have not had chickenpox as a child.
DIF: Cognitive Level: Apply
REF: p. 462
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A 13-year-old is being seen in the clinic for a routine health check. The adolescent has not been
in the clinic for 3 years but was up to date on immunizations at that time. Which immunizations
should the adolescent receive? (Select all that apply.)
a.
DTaP (tetanus, diphtheria, acellular pertussis)
b.
MMR (measles, mumps, rubella)
c.
Hepatitis B
d.
Influenza
e.
MCV4 (meningococcal)
ANS: A, D, E
The DTaP (tetanus, diphtheria, acellular pertussis) vaccine is recommended for adolescents 11 to
18 years old who have not received a tetanus booster (Td) or DTaP dose and have completed the
childhood DTaP/DTP series. Meningococcal vaccine (MCV4) should be given to adolescents 11
to 12 years of age with a booster dose at age 16 years. Annual influenza vaccination with either
the live attenuated influenza vaccine or trivalent influenza vaccine is recommended for all children and adolescents. The adolescent, previously up to date on vaccinations, would have received
the MMR and hepatitis B as a child.
DIF: Cognitive Level: Apply
REF: p. 462
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
2. The nurse should teach the adolescent that the long-term effects of tanning can cause which con-
ditions? (Select all that apply.)
a.
b.
c.
d.
e.
Phototoxic reactions
Increased number of moles
Premature aging
Striae
Increased risk of skin cancer
ANS: A, C, E
Long-term effects of tanning include premature aging of the skin, increased risk of skin cancer,
and, in susceptible individuals, phototoxic reactions. There has been no correlation to an increase
in moles or striae (streaks or stripes on the skin, usually on the abdomen) development.
DIF: Cognitive Level: Apply
REF: p. 463
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which screening tests should the school nurse perform for the adolescent? (Select all that apply.)
a.
Glucose
b.
Vision
c.
d.
e.
Hearing
Cholesterol
Scoliosis
ANS: B, C, E
The school nurse should perform vision, hearing, and scoliosis screening tests according to the
school district’s required schedule. Glucose and cholesterol screening would be performed in the
medical clinic setting.
DIF: Cognitive Level: Apply
REF: p. 461
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
COMPLETION
1. The estimated average requirement of calcium for an adolescent is _____ milligrams. (Record
your answer in a whole number.)
ANS:
1100
The EAR (estimated average requirement) for calcium in adolescents 14 to 18 years of age is
1100 mg.
DIF: Cognitive Level: Understand
REF: p. 459
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the sequence of maturational changes for girls. Begin with the first change seen,
sequencing to the last change. Provide answer in using lowercase letters, separated by commas
(e.g., a, b, c, d, e).
a. Growth of pubic hair
b. Rapid increase in height and weight
c. Breast changes
d. Menstruation
e. Appearance of axillary hair
ANS:
c, b, a, e, d
The usual sequence of maturational changes for girls is breast changes, rapid increase in height
and weight, growth of public hair, appearance of axillary hair, and then menstruation, which usually begins 2 years after the first signs.
DIF: Cognitive Level: Analyze
REF: p. 450
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 16: Health Problems of School-Age Children and Adolescents
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which statement is true about smoking in adolescence?
a. Smoking is related to other high-risk behaviors.
b. Smoking will not continue unless peer pressure continues.
c. Smoking is less common when the adolescent’s parent(s) smokes.
d. Smoking among adolescents is becoming more prevalent.
ANS: A
Cigarettes are considered a gateway drug. Teenagers who smoke are 11.4 times more likely to
use an illicit drug. Teenagers begin smoking for a variety of reasons, such as imitation of
adult behavior, peer pressure, imitation of behaviors portrayed in movies and advertisements,
and a desire to control weight. The absence of peer pressure alone will not stop smoking.
Teenagers who do not smoke usually have parents and friends who do not smoke or who
oppose smoking. The percentage of young people who report current cigarette use and
frequent cigarette use has declined significantly.
DIF: Cognitive Level: Understand
REF: p. 492
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. What is smokeless tobacco?
a. Not addicting
b. Proven to be carcinogenic
c. Easy to stop using
d. A safe alternative to cigarette smoking
ANS: B
Smokeless tobacco is a popular substitute for cigarettes and poses serious health hazards to
children and adolescents. Smokeless tobacco is associated with cancer of the mouth and jaw.
The nicotine in the smokeless tobacco is addicting, and therefore it is very difficult to quit.
Because the product is addicting and can cause cancer, it is not a safe alternative to cigarette
smoking.
DIF: Cognitive Level: Remember
REF: p. 492
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A child has been diagnosed with enuresis. TCA imipramine (Tofranil) has been prescribed for
the child. The nurse understands that this medication is in which category?
a. Antidepressant
b. Antidiuretic
c. Antispasmodic
d. Analgesic
ANS: C
Drug therapy is increasingly being prescribed to treat enuresis. Three types of drugs are used:
tricyclic antidepressants (TCAs), antidiuretics, and antispasmodics. The selection depends on
the interpretation of the cause. The drug used most frequently is the TCA imipramine
(Tofranil), which exerts an anticholinergic action in the bladder to inhibit urination. Tofranil
is in the antispasmodic category. Analgesics are not used to treat enuresis.
DIF: Cognitive Level: Remember
REF: p. 466
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
4. A 12-year-old male has short stature because of a constitutional growth delay. What should
the nurse be the most concerned about?
a. Proper administration of thyroid hormone
b. Proper administration of human growth hormones
c. Child’s self-esteem and sense of competence
d. Helping child understand that his height is most likely caused by chronic illness
and is not his fault
ANS: C
Most cases of constitutional growth delay are caused by simple constitutional delay of
puberty, and the child can be assured that normal development will eventually take place.
Listening to distressed adolescents and conveying interest and concern are important
interventions for these children and adolescents. They should be encouraged to focus on the
positive aspects of their bodies and personalities. Thyroid hormones and human growth
hormones would not be beneficial in a constitutional growth delay. A constitutional growth
delay is not caused by a chronic illness.
DIF: Cognitive Level: Understand
REF: p. 483
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
5. An adolescent asks the nurse what causes primary dysmenorrhea. The nurse’s response
should be based on which statement?
a. It is an inherited problem.
b. Excessive estrogen production causes uterine pain.
c. There is no physiologic cause; it is a psychological reaction.
d. There is a relation between prostaglandins and uterine contractility.
ANS: D
The exact etiology of primary dysmenorrhea is debated. Overproduction of uterine
prostaglandins has been implicated, as has overproduction of vasopressin. Dysmenorrhea is
not known to be inherited. Excessive estrogen has not been implicated in the etiology. It has a
physiologic cause. Women with dysmenorrhea have higher prostaglandin levels.
DIF: Cognitive Level: Apply
REF: p. 475
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. An adolescent girl asks the school nurse for advice because she has dysmenorrhea. She says
that a friend recommended she try an over-the-counter nonsteroidal anti-inflammatory drug
(NSAID). The nurse’s response should be based on which statement?
a. Aspirin is the drug of choice for the treatment of dysmenorrhea.
b. Over-the-counter NSAIDs are rarely strong enough to provide adequate pain relief.
c. NSAIDs are effective because of their analgesic effect.
d. NSAIDs are effective because they inhibit prostaglandins, leading to reduction in
uterine activity.
ANS: D
First-line therapy for adolescents with dysmenorrhea is NSAIDs. This group of drugs blocks
the formation of prostaglandins. NSAIDs, not aspirin, are the drugs of choice in
dysmenorrhea. NSAIDs are potent anti-inflammatory agents that inhibit prostaglandin.
Although NSAIDs have analgesic effects, the mechanism of action in dysmenorrhea is most
likely the antiprostaglandin effect.
DIF: Cognitive Level: Apply
REF: p. 475
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. A 14-year-old boy and his parents are concerned about bilateral breast enlargement. The
nurse’s discussion of this should be based on which statement?
This is usually benign and temporary.
This is usually caused by Klinefelter syndrome.
Administration of estrogen effectively reduces gynecomastia.
Administration of testosterone effectively reduces gynecomastia.
a.
b.
c.
d.
ANS: A
The male breast responds to hormonal changes. Some degree of bilateral or unilateral breast
enlargement occurs frequently in boys during puberty. Although individuals with Klinefelter
syndrome can have gynecomastia, it is not a common cause for male breast enlargement.
Estrogen is not a therapy for gynecomastia. Administration of testosterone has no benefit for
gynecomastia and may aggravate the condition.
DIF: Cognitive Level: Understand
REF: p. 474
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4
months ago. She has not received any medical care. She smokes but denies any other
substance use. What is the priority nursing action?
a. Notify her parents
b. Refer for prenatal care
c. Explain the importance of not smoking
d. Discuss dietary needs for adequate fetal growth
ANS: B
Teenage girls and their unborn children are at greater risk for complications during pregnancy
and delivery. With improved therapies, the mortality for teenage pregnancy is decreasing, but
the morbidity is high. A pregnant teenager needs careful assessment by the nurse to determine
the level of social support available to her and possibly her partner. Guidance from the adults
in her life would be invaluable, but confidentiality should be maintained. Although it is
important to explain the importance of not smoking and to discuss dietary needs for adequate
fetal growth, because of her potential for having a high-risk pregnancy, she will need a
comprehensive prenatal program to minimize maternal-fetal complications.
DIF: Cognitive Level: Apply
REF: p. 476
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. An adolescent girl calls the nurse at the clinic because she had unprotected sex the night
before and does not want to be pregnant. What should the nurse explain to the girl?
a. It is too late to prevent an unwanted pregnancy
b. An abortion may be the best option if she is pregnant
c. Norplant can be administered to prevent pregnancy for up to 5 years
d. Postcoital contraception is available to prevent implantation
ANS: D
Several emergency methods of contraception are available. Postcoital contraception options
do exist. It is nontherapeutic to tell her it is too late or that an abortion is the best option.
Norplant is not a postcoital contraceptive.
DIF: Cognitive Level: Apply
REF: p. 480
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. A sexually active female adolescent asks the nurse about the contraceptive Depo-Provera.
What should the nurse explain regarding the contraceptive?
Requires injections every 3 months
Requires daily administration of medication by mouth
Provides long-term continuous protection, up to 5 years
Prevents pregnancy if given within 72 hours of unprotected sex
a.
b.
c.
d.
ANS: A
The contraceptive Depo-Provera is administered by injection every 3 months. Oral
contraceptives, not Depo-Provera, require daily administration of medication by mouth.
Norplant, not Depo-Provera, provides long-term continuous protection for up to 5 years.
Postcoital contraception, not Depo-Provera, prevents pregnancy if given within 72 hours of
unprotected sex.
DIF: Cognitive Level: Understand
REF: p. 477
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
11. Which statement is true about gonorrhea?
a. It is caused by Treponema pallidum.
b. Treatment is by multidose administration of penicillin.
c. Treatment is by topical applications to lesions.
d. Treatment of all sexual contacts is an essential part of treatment.
ANS: D
The treatment plan should include finding and treating all sexual partners. Gonorrhea is
caused by Neisseria gonorrhoeae. Syphilis is caused by T. pallidum. Primary treatment is
with different antibiotics because of N. gonorrhoeae resistance to penicillin. Systemic therapy
is necessary to treat this disease.
DIF: Cognitive Level: Understand
REF: p. 480
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. Which statement regarding chlamydia infection is correct?
a. Treatment of choice is oral penicillin.
b. Treatment of choice is nystatin or miconazole.
c. Clinical manifestations include dysuria and urethral itching in males.
d. Clinical manifestations include small, painful vesicles on genital areas.
ANS: C
Symptoms of chlamydia infection in males include meatal erythema, tenderness, itching,
dysuria, and urethral discharge. Some infected males have no symptoms. Oral penicillin and
nystatin or miconazole are not the antibiotics of choice. Small, painful vesicles on genital
areas are clinical manifestations true of chlamydia infection but may also indicate herpetic
lesions.
DIF: Cognitive Level: Understand
REF: p. 480
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. A nurse is conducting a class for adolescent girls about pelvic inflammatory disease (PID).
Why should the nurse emphasize the importance of preventing pelvic inflammatory disease
(PID)?
a. PID can be sexually transmitted.
b. PID cannot be treated.
c. PID can have devastating effects on the reproductive tract.
d. PID can cause serious defects in future children of affected adolescents.
ANS: C
PID is a major concern because of its devastating effects on the reproductive tract. Short-term
complications include abscess formation in the fallopian tubes, whereas long-term
complications include ectopic pregnancy, infertility, and dyspareunia. PID is an infection of
the upper female genital tract, most commonly caused by sexually transmitted infections but
it is not sexually transmitted to another person. PID can be treated by treating the underlying
cause. There is a possibility of ectopic pregnancy but not birth defects in children.
DIF: Cognitive Level: Apply
REF: p. 480
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. Which statement is correct about childhood obesity?
a. Heredity is an important factor in the development of obesity.
b. Childhood obesity in the United States is decreasing.
c. Childhood obesity is the result of inactivity.
d. Childhood obesity can be attributed to an underlying disease in most cases.
ANS: A
Heredity is an important fact that contributes to obesity. Identical twins reared apart tend to
resemble their biologic parents to a greater extent than their adoptive parents. It is difficult to
distinguish between hereditary and environmental factors. The number of overweight
children is increasing in the United States. Inactivity is related to childhood obesity, but it is
not the only component. Underlying diseases such as hypothyroidism and hyperinsulinism
account for only a small number of cases of childhood obesity.
DIF: Cognitive Level: Understand
REF: p. 483
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. What is a psychological effect of being obese during adolescence?
a. Sexual promiscuity
b. Poor body image
c. Feelings of contempt for thin peers
d. Accurate body image but self-deprecating attitude
ANS: B
Common emotional consequences of obesity include poor body image, low self-esteem,
social isolation, and feelings of depression and isolation. Sexual promiscuity, feelings of
contempt for thin peers, and accurate body image but self-deprecating attitude are not usually
associated with obesity.
DIF: Cognitive Level: Understand
REF: p. 483
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
16. What is the best description of anorexia nervosa?
a. Occurs most frequently in adolescent males
b. Occurs most frequently in adolescents from lower socioeconomic groups
c. Results from a posterior pituitary disorder
d. Results in severe weight loss in the absence of obvious physical causes
ANS: D
The etiology of anorexia remains unclear, but a distinct psychological component is present.
The diagnosis is based primarily on psychological and behavioral criteria. Females account
for 90% to 95% of the cases. No relation has been identified between socioeconomic groups
and anorexia. Posterior pituitary disorders are not associated with anorexia nervosa.
DIF: Cognitive Level: Remember
REF: p. 488
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. How are young people with anorexia nervosa often described?
a. Independent
b. Disruptive
c. Conforming
d. Low achieving
ANS: C
Individuals with anorexia nervosa are described as perfectionist, academically high achievers,
conforming, and conscientious. “Independent,” disruptive,” and “low achieving” are not part
of the behavioral characteristics of anorexia nervosa.
DIF: Cognitive Level: Understand
REF: p. 488
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
18. What usually triggers the weight loss of anorexia nervosa?
a. Sexual abuse
b. School failure
c. Independence from family
d. Traumatic interpersonal conflict
ANS: D
Weight loss may be triggered by a typical adolescent crisis such as the onset of menstruation
or a traumatic interpersonal incident; situations of severe family stress, such as parental
separation or divorce; or circumstances in which the young person lacks personal control,
such as being teased, changing schools, or entering college. “Sexual abuse,” “school failure,”
and “independence from family” are not part of the behavioral characteristics of anorexia
nervosa.
DIF: Cognitive Level: Understand
REF: p. 488
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
19. Which symptoms should the nurse expect to observe during the physical assessment of an
adolescent girl with severe weight loss and disrupted metabolism associated with anorexia
nervosa?
a. Dysmenorrhea and oliguria
b. Tachycardia and tachypnea
c. Heat intolerance and increased blood pressure
d. Lowered body temperature and brittle nails
ANS: D
Symptoms of anorexia nervosa include lower body temperature, severe weight loss,
decreased blood pressure, dry skin, brittle nails, altered metabolic activity, and presence of
lanugo hair. Amenorrhea, rather than dysmenorrhea, and cold intolerance are manifestations
of anorexia nervosa. Bradycardia, rather than tachycardia, may be present.
DIF: Cognitive Level: Understand
REF: p. 488
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. Which is descriptive of bulimia during adolescence?
a. Strong sense of control over eating behavior
b. Feelings of elation after the binge-purge cycle
c. Profound lack of awareness that the eating pattern is abnormal
d. Weight that can be normal, slightly above normal, or below normal
ANS: D
Individuals with bulimia are of normal or more commonly slightly above normal weight.
Those who also restrict their intake can become severely underweight. The adolescent has a
lack of control over eating during the episode. Patients with bulimia commonly have selfdeprecating thoughts and a depressed mood after binge-purge cycles; they are also aware that
the eating pattern is abnormal but are unable to stop.
DIF: Cognitive Level: Understand
REF: p. 488
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
21. An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?
a. Diarrhea
b. Amenorrhea
c. Cold intolerance
d. Erosion of tooth enamel
ANS: D
Some of the signs of bulimia include erosion of tooth enamel, increased dental caries from
vomited gastric acid, throat complaints, fluid and electrolyte disturbances, and abdominal
complaints from laxative abuse. Diarrhea is not a result of the vomiting. It may occur in
patients with bulimia who also abuse laxatives. Amenorrhea and cold intolerance are
characteristics of anorexia nervosa, which some bulimics have. These symptoms are related
to the extreme low weight.
DIF: Cognitive Level: Apply
REF: p. 488
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. Which is descriptive of attention deficit hyperactivity disorder (ADHD)?
a. Manifestations exhibited are so bizarre that the diagnosis is fairly easy.
b. Manifestations affect every aspect of the child’s life but are most obvious in the
classroom.
c. Learning disabilities associated with ADHD eventually disappear when adulthood
is reached.
d. Diagnosis of ADHD requires that all manifestations of the disorder be present.
ANS: B
ADHD affects every aspect of the child’s life, but the disruption is most obvious in the
classroom. The behaviors exhibited by the child with ADHD are not unusual aspects of
behavior. The difference lies in the quality of motor activity and developmentally
inappropriate inattention, impulsivity, and hyperactivity that the child displays. Some
children experience decreased symptoms during late adolescence and adulthood, but a
significant number carry their symptoms into adulthood. Any given child will not have every
symptom of the condition. The manifestations may be numerous or few, mild or severe, and
will vary with the child’s developmental level.
DIF: Cognitive Level: Understand
REF: p. 468
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. The nurse is teaching the parents of a child recently diagnosed with ADHD who has been
prescribed methylphenidate (Ritalin). Which should the nurse include in teaching about the
side effects of methylphenidate?
a. “Your child may experience a sense of nervousness.”
b. “You may see an increase in your child’s appetite.”
c. “Your child may experience daytime sleepiness.”
d. “You may see a decrease in your child’s blood pressure.”
ANS: A
Nervousness is one of the common side effects of Ritalin. Decreased appetite with
subsequent weight loss, insomnia, and increased blood pressure are other common side
effects.
DIF: Cognitive Level: Apply
REF: p. 469
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
24. Which is an important consideration when the nurse is discussing enuresis with the parents of
a young child?
Enuresis is more common in girls than in boys.
Enuresis is neither inherited nor has a familial tendency.
Organic causes that may be related to enuresis should be considered first.
Psychogenic factors that cause enuresis persist into adulthood.
a.
b.
c.
d.
ANS: C
Organic causes that may be related to enuresis should be ruled out before psychogenic factors
are considered. Enuresis is more common in boys than in girls and has a strong familial
tendency. Psychogenic factors may influence enuresis, but it is doubtful that they are
causative.
DIF: Cognitive Level: Apply
REF: p. 466
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. The nurse is assisting the family of a child with a history of encopresis. Which should be
included in the nurse’s discussion with this family?
a. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
b. Instruct the parents that the child will probably need to have daily enemas.
c. Suggest the use of stimulant cathartics weekly.
d. Reassure the family that most problems are resolved successfully, with some
relapses during periods of stress.
ANS: D
Children may be unaware of a prior sensation and unable to control the urge once it begins.
They may be so accustomed to bowel accidents that they are unable to smell or feel it. Family
counseling is directed toward reassurance that most problems resolve successfully, although
relapses during periods of stress are possible. Sitting the child on the toilet is not
recommended because it may intensify the parent-child conflict. Enemas may be needed for
impactions, but long-term use prevents the child from assuming responsibility for defecation.
Stimulant cathartics may cause cramping that can frighten the child.
DIF: Cognitive Level: Apply
REF: p. 467
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. A mother calls the school nurse saying that her daughter has developed a school phobia. She
has been out of school 3 days. The nurse’s recommendations should include which
intervention?
a. Immediately return the child to school.
b. Explain to the child that this is the last day she can stay home.
c. Determine the cause of phobia before returning the child to school.
d. Seek professional counseling before forcing the child to return to school.
ANS: A
The primary goal is to return the child to school. Parents must be convinced gently, but
firmly, that immediate return is essential and that it is their responsibility to insist on school
attendance. The longer the child is permitted to stay out of school, the more difficult it will be
for the child to reenter. Trying to find the cause of phobia will only delay the return to school
and inhibit the child’s ability to cope. Professional counseling is recommended if the problem
persists, but the child’s return to school should not wait for the counseling.
DIF: Cognitive Level: Apply
REF: p. 470
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
27. Parents have a concern that their child is depressed. The nurse relates that which
characteristic best describes children with depression?
Increased range of affective response
Preoccupation with need to perform well in school
Change in appetite, resulting in weight loss or gain
Tendency to prefer play instead of schoolwork
a.
b.
c.
d.
ANS: C
Physiologic characteristics of children with depression include change in appetite resulting in
weight loss or gain, nonspecific complaints of not feeling well, alterations in sleeping pattern,
insomnia or hypersomnia, and constipation. Children who are depressed have sad facial
expressions with absence or diminished range of affective response. These children withdraw
from previously enjoyed activities and engage in solitary play or work with a lack of interest
in play. A lack of interest is seen in doing homework or achieving in school, resulting in
lower grades in children who are depressed.
DIF: Cognitive Level: Apply
REF: p. 471
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
28. A teen asks a nurse, “What is physical dependence in substance abuse?” Which is the correct
response by the nurse?
Problem that occurs in conjunction with addiction
Involuntary physiologic response to drug
Culturally defined use of drugs for purposes other than accepted medical purposes
Voluntary behavior based on psychosocial needs
a.
b.
c.
d.
ANS: B
Physical dependence is an involuntary response to the pharmacologic characteristics of drugs
such as opioids or alcohol. A person can be physically dependent on a narcotic/drug without
being addicted; for example, patients who use opioids to control pain need increasing doses
to achieve the same effect. Dependence is a physiologic response; it is not culturally
determined or subject to voluntary control.
DIF: Cognitive Level: Apply
REF: p. 492
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
29. Which is descriptive of central nervous system stimulants?
a. They produce strong physical dependence.
b. They can result in strong psychological dependence.
c. Withdrawal symptoms are life threatening.
d. Acute intoxication can lead to coma.
ANS: B
Central nervous system stimulants such as amphetamines and cocaine produce a strong
psychological dependence. This class of drugs does not produce strong physical dependence
and can be withdrawn without much danger. Acute intoxication leads to violent, aggressive
behavior or psychotic episodes characterized by paranoia, uncontrollable agitation, and
restlessness.
DIF: Cognitive Level: Understand
REF: p. 494
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
30. The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine
is believed to be the drug involved. Data collection should include what information?
a. Mode of administration
b. Drug’s actual content
c. Function the drug plays in the adolescent’s life
d. Adolescent’s level of interest in rehabilitation
ANS: A
When the drug is questionable or unknown, every effort must be made to determine the type,
amount of drug taken, the mode and time of administration, and factors relating to the onset
of presenting symptoms. The actual content of most street drugs is highly questionable.
Pharmacologic agents should be administered with caution, except for the narcotic
antagonists in case of suspected opioid use. The function the drug plays in the adolescent’s
life and the adolescent’s level of interest in rehabilitation are important considerations in the
long-term management during the non-acute stage.
DIF: Cognitive Level: Apply
REF: p. 495
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
31. A school nurse is conducting a class with adolescents on suicide. Which true statement about
suicide should the nurse include in the teaching session?
A sense of hopelessness and despair are a normal part of adolescence.
Gay and lesbian adolescents are at a particularly high risk for suicide.
Problem-solving skills are of limited value to the suicidal adolescent.
Previous suicide attempts are not an indication of risk for completed suicides.
a.
b.
c.
d.
ANS: B
A significant number of teenage suicides occur among homosexual youths. Gay and lesbian
adolescents who live in families or communities that do not accept homosexuality are likely
to suffer low self-esteem, self-loathing, depression, and hopelessness as a result of a lack of
acceptance from their family or community. At-risk teenagers include those who are
depressed, have poor problem-solving skills, or use drugs and alcohol. History of previous
suicide attempt is a serious indicator for possible suicide completion in the future.
DIF: Cognitive Level: Apply
REF: p. 496
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
32. Which is the most commonly used method in completed suicides?
a. Firearms
b. Drug overdose
c. Self-inflected laceration
d. Carbon monoxide poisoning
ANS: A
Firearms are the most commonly used instruments in completed suicides among both males
and females. For adolescent boys, firearms are followed by hanging and overdose. For
adolescent females, overdose and strangulation are the next most common means of
completed suicide. The most common method of suicide attempt is overdose or ingestion of
potentially toxic substances such as drugs. The second most common method of suicide
attempt is self-inflicted laceration. Carbon monoxide poisoning is not one of the more
frequent forms of suicide completion.
DIF: Cognitive Level: Remember
REF: p. 496
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
33. Which is the most significant factor in distinguishing those who commit suicide from those
who make suicidal attempts or threats?
Social isolation
Level of stress
Degree of depression
Desire to punish others
a.
b.
c.
d.
ANS: A
Social isolation is a significant factor in distinguishing adolescents who will kill themselves
from those who will not. It is also more characteristic of those who complete suicide than of
those who make attempts or threats. Level of stress, degree of depression, and desire to
punish others are contributing factors in suicide, but they are not the most significant factor in
distinguishing those who complete suicide from those who attempt suicide.
DIF: Cognitive Level: Understand
REF: p. 496
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
34. An adolescent girl tells the nurse that she is very suicidal. The nurse asks her whether she has
a specific plan. Asking this should be considered:
an appropriate part of the assessment.
not a critical part of the assessment.
suggesting that the adolescent needs a plan.
encouraging the adolescent to devise a plan.
a.
b.
c.
d.
ANS: A
Routine health assessments of adolescents should include questions that assess the presence
of suicidal ideation or intent. Questions such as, “Have you ever developed a plan to hurt
yourself or kill yourself?” should be part of that assessment. Adolescents who express
suicidal feelings and have a specific plan are at particular risk and require further assessment
and constant monitoring. The information about having a plan is an essential part of the
assessment and greatly affects the treatment plan.
DIF: Cognitive Level: Understand
REF: p. 496
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
35. An adolescent has been diagnosed with lactose maldigestion intolerance. The nurse teaches
the adolescent about lactose maldigestion intolerance and notes the teen needs further
teaching if which statement is made?
a. “I will limit my milk consumption to one to two glasses a day.”
b. “I should drink the milk alone and not with other foods.”
c. “Hard cheese, cottage cheese, or yogurt can be substituted for milk.”
d. “I will take a calcium supplement daily.”
ANS: B
Most people are able to tolerate small amounts of lactose (»1 cup of milk per day) even in
the presence of deficient lactase activity. It is recommended that individuals with lactose
maldigestion who do not experience lactose intolerance symptoms continue to consume small
amounts of dairy products with meals to prevent reduced bone mass density and subsequent
osteoporosis. Hard cheese, cottage cheese, and yogurt are sources of lactose that may be
better tolerated. A calcium supplement should be taken daily. Milk taken at meals may be
better tolerated than when taken alone.
DIF: Cognitive Level: Apply
REF: p. 491
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
36. An adolescent has been diagnosed with Chlamydia infection. Which medication should the
nurse expect to be prescribed for this condition?
a. Ceftriaxone (Rocephin) IM
b. Azithromycin (Zithromax) PO
c. Acyclovir (Zovirax) PO
d. Penicillin G benzathine (Bicillin) IV
ANS: B
Azithromycin is used to treat Chlamydia. The patient should be rescreened in 3 to 4 months.
Ceftriaxone is used to treat gonorrhea, acyclovir is used to suppress genital herpes simplex
virus, and penicillin G benzathine is used to treat syphilis.
DIF: Cognitive Level: Understand
REF: p. 481
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
37. Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations
with this drug should include:
a. teaching to avoid use of sunscreen agents.
b. applying generously to the skin.
c. explaining that medication should not be applied until at least 20 to 30 minutes
after washing.
d. explaining that erythema and peeling are indications of toxicity.
ANS: C
The medication should not be applied for at least 20 to 30 minutes after washing to decrease
the burning sensation. The avoidance of sun and the use of sunscreen agents must be
emphasized because sun exposure can result in severe sunburn. The agent should be applied
sparingly to the skin. Erythema and peeling are common local manifestations.
DIF: Cognitive Level: Apply
REF: p. 473
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
38. When is isotretinoin (Accutane) indicated for the treatment of acne during adolescence?
a. The acne has not responded to other treatments.
b. The adolescent is or may become pregnant.
c. The adolescent is unable to give up foods causing acne.
d. Frequent washing with antibacterial soap has been unsuccessful.
ANS: A
Isotretinoin is reserved for severe cystic acne that has not responded to other treatments.
Isotretinoin has teratogenic effects and should never be used when there is a possibility of
pregnancy. No correlation exists between foods and acne. Antibacterial soaps are ineffective.
Frequent washing with antibacterial soap is not a recommended therapy for acne.
DIF: Cognitive Level: Understand
REF: p. 473
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. A nurse is recommending strategies to a group of school-age children for prevention of
obesity. Which should the nurse include? (Select all that apply.)
Eat breakfast daily.
Limit fruits and vegetables.
Have frequent family meals with parents present.
Eat frequently at restaurants.
Limit television viewing to 2 hours a day.
a.
b.
c.
d.
e.
ANS: A, C, E
The nurse should counsel school-age children to eat breakfast daily, have mealtimes with
family, and limit television viewing to 2 hours a day to prevent obesity. Fruits and vegetables
should be consumed in the recommended quantities, and eating at restaurants should be
limited.
DIF: Cognitive Level: Analyze
REF: p. 483
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which strategies should the school nurse recommend implementing in the classroom for a
child with attention deficit hyperactive disorder (ADHD)? (Select all that apply.)
Schedule heavier subjects to be taught in the afternoon.
Accompany verbal instructions by written format.
Limit number of breaks taken during instructional periods.
Allow more time for testing.
Reduce homework and classroom assignments.
a.
b.
c.
d.
e.
ANS: B, D, E
Children with ADHD need an orderly, predictable, and consistent classroom environment
with clear and consistent rules. Homework and classroom assignments may need to be
reduced, and more time may need to be allotted for tests to allow the child to complete the
task. Verbal instructions should be accompanied by visual references such as written
instructions on the blackboard. Schedules may need to be arranged so that academic subjects
are taught in the morning when the child is experiencing the effects of the morning dose of
medication. Regular and frequent breaks in activity are helpful because sitting in one place
for an extended time may be difficult.
DIF: Cognitive Level: Apply
REF: p. 468
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which side effects should the nurse monitor when a child is taking an antipsychotic
medication? (Select all that apply.)
Extrapyramidal effects
Hypertension
Bradycardia
Dizziness
Seizures
a.
b.
c.
d.
e.
ANS: A, D, E
Common side effects of antipsychotic medications include dizziness, drowsiness,
tachycardia, hypotension, and extrapyramidal effects, such as abnormal movements and
seizures.
DIF: Cognitive Level: Understand
REF: p. 472
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
Chapter 17: Quality of Life for Children Living with Chronic and Complex Diseases
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse case manager is planning a care conference about a young child who has complex
health care needs and will soon be discharged home. Who should the nurse invite to the
conference?
a. Family and nursing staff
b. Social worker, nursing staff, and primary care physician
c. Family and key health professionals involved in the child’s care
d. Primary care physician and key health professionals involved in the child’s care
ANS: C
A multidisciplinary conference is necessary for coordination of care for children with
complex health needs. The family is included, along with key health professionals who are
involved in the child’s care. The nursing staff can address the child’s nursing care needs with
the family, but other involved disciplines must be included. The family must be included in
the discharge conferences, which allows them to determine what education they will require
and the resources needed at home. A member of the nursing staff must be included to review
the child’s nursing needs.
DIF: Cognitive Level: Analyze
REF: p. 501
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
2. Which represents a common best practice in the provision of services to children with special
needs?
a. Care is now being focused on the child’s chronologic age.
b. Children with special needs are being integrated into regular classrooms.
c. Children with special needs no longer have to be cared for by their families.
d. Children with special needs are being separated into residential treatment facilities.
ANS: B
Normalization refers to behaviors and interventions for the disabled to integrate into society
by living life as persons without a disability would. For children, normalization includes
attending school and being integrated into regular classrooms. This affords the child the
advantages of learning with a wide group of peers. Care is necessarily focused on the child’s
developmental age. Home care by the family is considered best practice. The nurse can assist
families by assessing social support systems, coping strategies, family cohesiveness, and
family and community resources.
DIF: Cognitive Level: Understand
REF: p. 502
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
3. Lindsey, age 5 years, will be starting kindergarten next month. She has cerebral palsy, and it
has been determined that she needs to be in a special education classroom. Her parents are
tearful when telling the nurse about this and state that they did not realize her disability was
so severe. What is the best interpretation of this situation?
a. This is a sign parents are in denial
b. This is a normal anticipated time of parental stress
c. The parents need to learn more about cerebral palsy
d. The parents are used to having expectations that are too high
ANS: B
Parenting a child with a chronic illness can be stressful for parents. There are anticipated
times that parental stress increases. One of these identified times is when the child begins
school. Nurses can help parents recognize and plan interventions to work through these
stressful periods. The parents are not in denial; they are responding to the child’s placement
in school. The parents are not exhibiting signs of a knowledge deficit; this is their first
interaction with the school system with this child.
DIF: Cognitive Level: Analyze
REF: p. 517
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
4. Approach behaviors are those coping mechanisms that result in a family’s movement toward
adjustment and resolution of the crisis of having a child with a chronic illness or disability.
Which is considered an approach behavior?
a. Is unable to adjust to a progression of the disease or condition
b. Anticipates future problems and seeks guidance and answers
c. Looks for new cures without a perspective toward possible benefit
d. Fails to recognize the seriousness of the child’s condition despite physical evidence
ANS: B
The parents who anticipate future problems and seek guidance and answers are demonstrating
approach behaviors. They are demonstrating positive actions in caring for their child. Being
unable to adjust to a progression of the disease or condition, looking for new cures without a
perspective toward possible benefit, and failing to recognize the seriousness of a child’s
condition despite physical evidence are avoidance behaviors. The parents are moving away
from adjustment (and toward maladaptation) in the crisis of a child with chronic illness or
disability.
DIF: Cognitive Level: Understand
REF: p. 506
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
5. Families progress through various stages of reactions when a child is diagnosed with a
chronic illness or disability. After the shock phase, a period of adjustment usually follows.
This is often characterized by which of the following responses?
a. Denial
b. Guilt and anger
c. Social reintegration
d. Acceptance of the child’s limitations
ANS: B
For most families, the adjustment phase is accompanied by several responses. Guilt, selfaccusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic
illness or disability often is met with intense emotion, characterized by shock and denial.
Social reintegration and acceptance of the child’s limitations are the culmination of the
adjustment process.
DIF: Cognitive Level: Understand
REF: p. 506
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
6. Which nursing intervention is especially helpful in assessing parental guilt when a disability
or chronic illness is diagnosed?
Ask the parents if they feel guilty.
Discuss guilt only after the parents mention it.
Discuss the meaning of the parents’ religious and cultural background.
Observe for signs of overprotectiveness.
a.
b.
c.
d.
ANS: C
Guilt may be associated with cultural or religious beliefs. Some parents are convinced that
they are being punished for some previous misdeed. Others may see the disorder as a
sacrifice sent by God to test their religious beliefs. The nurse can help the parents explore
their religious beliefs. The parents may not be able to identify the feelings of guilt. It would
be appropriate for the nurse to explore their adjustment responses. Overprotectiveness is a
parental response during the adjustment phase. The parents fear letting the child achieve any
new skill and avoid all discipline.
DIF: Cognitive Level: Apply
REF: p. 506
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
7. The nurse observes that a seriously ill child passively accepts all painful procedures. What
should the nurse recognize this child is most likely experiencing?
A sense of hopefulness
A sense of chronic sorrow
A belief that procedures are a deserved punishment
A belief that procedures are an important part of care
a.
b.
c.
d.
ANS: C
The nurse should be particularly alert to the child who passively accepts all painful
procedures. This child may believe that such acts are inflicted as deserved punishment. The
child who is hopeful is mobilized into goal-directed actions. This child would actively
participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves over
time. It is usually evident in the parents, not in the child. A child who believes that procedures
are an important part of care would actively participate in care. Nursing interventions should
be used to minimize the pain.
DIF: Cognitive Level: Analyze
REF: p. 507
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
8. The nurse comes into the room of a child who was just diagnosed with a chronic disability.
The child’s parents begin to yell at the nurse about a variety of concerns. Which is the nurse’s
best response?
a. “What is really wrong?”
b. “Being angry is only natural.”
c. “Yelling at me will not change things.”
d. “I will come back when you settle down.”
ANS: B
Parental anger after the diagnosis of a child with a chronic disability is a common response.
One of the most common targets for parental anger is members of the staff. The nurse should
recognize the common response of anger to the diagnosis and allow the family to vent. “What
is really wrong?”/“Yelling at me will not change things”/“I will come back when you settle
down” will place the parents on the defensive and not facilitate communication.
DIF: Cognitive Level: Apply
REF: p. 514
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
9. A common parental reaction to a child with special needs is parental overprotection. What
parental behavior is suggestive of this behavior?
Giving inconsistent discipline
Providing consistent, strict discipline
Forcing child to help self, even when not capable
Encouraging social and educational activities not appropriate to child’s level of
capability
a.
b.
c.
d.
ANS: A
Parental overprotection is manifested by the parents’ fear of letting the child achieve any new
skill; they allow the child to avoid all discipline and cater to every desire to prevent
frustration. Overprotective parents do not set limits and or institute discipline; prefer to
remain in the role of total caregiver; do not allow the child to perform self-care; and do not
encourage the child to participate in social and educational activities.
DIF: Cognitive Level: Analyze
REF: p. 516
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
10. Most parents of children with special needs tend to experience chronic sorrow. What
characterizes chronic sorrow?
a. Lack of acceptance of the child’s limitation
b. Lack of available support to prevent sorrow
c. Periods of intensified sorrow when experiencing anger and guilt
d. Periods of intensified sorrow and loss that occur in waves over time
ANS: D
Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time.
The sorrow is in response to the recognition of the child’s limitations. The family should be
assessed in an ongoing manner to provide appropriate support as the needs of the family
change. The sorrow is not preventable. The chronic sorrow occurs during the reintegration
and acknowledgment stage.
DIF: Cognitive Level: Understand
REF: p. 507
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
11. Which intervention will encourage a sense of autonomy in a toddler with disabilities?
a. Avoid separation from family during hospitalizations.
b. Encourage independence in as many areas as possible.
c. Expose child to pleasurable experiences as much as possible.
d. Help parents learn special care needs of their child.
ANS: B
Encouraging the toddler to be independent encourages a sense of autonomy. The child can be
given choices about feeding, dressing, and diversional activities, which will provide a sense
of control. Avoiding separation from family during hospitalizations, and helping parents learn
special care needs of their child should be practiced as part of family-centered care. It does
not necessarily foster autonomy. Exposing the child to pleasurable experiences, especially
sensory ones, is a supportive intervention. It does not promote autonomy.
DIF: Cognitive Level: Apply
REF: p. 509
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
12. The feeling of guilt that the child “caused” the disability or illness is especially critical in
which child?
a. Toddler
b. Preschooler
c. School-age child
d. Adolescent
ANS: B
Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or
disability or are being punished for wrongdoings. Toddlers are focused on establishing their
autonomy. The illness will foster dependence. The school-age child will have limited
opportunities for achievement and may not be able to understand limitations. Adolescents
face the task of incorporating their disabilities into their changing self-concept.
DIF: Cognitive Level: Understand
REF: p. 521
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
13. A 9-year-old boy has several physical disabilities. His father explains to the nurse that his son
concentrates on what he can, rather than cannot, do and is as independent as possible. What is
the nurse’s best interpretation of this statement?
a. The father is experiencing denial
b. The father is expressing his own views
c. The child is using an adaptive coping style
d. The child is using a maladaptive coping style
ANS: C
The father is describing a well-adapted child who has learned to accept physical limitations.
These children function well at home, at school, and with peers. They have an understanding
of their disorder that allows them to accept their limitations, assume responsibility for care,
and assist in treatment and rehabilitation. The father is describing his child’s behavior. He is
not denying the child’s limitations. The father is exhibiting an adaptive coping style.
DIF: Cognitive Level: Analyze
REF: p. 508
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
14. The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The
parent is upset and tearful. The nurse asks, “Whom do you talk to when something is
worrying you?” How should the nurse’s statement be interpreted?
a. Inappropriate, because the parent is so upset
b. A diversion of the present crisis to similar situations with which the parent has
dealt
c. An intervention to find someone to help the parent
d. Part of assessing the parent’s available support system
ANS: D
These are important data for the nurse to obtain. This question will provide information about
the marital relationship (whether the parent speaks to the spouse), alternate support systems,
and ability to communicate. By assessing these areas, the nurse can facilitate the
identification and use of community resources as needed. It is an important part of
assessment information to determine the parent’s support network. The nurse is obtaining
information to help support the parent through the diagnosis. The parent is not in need of
additional parenting help at this time.
DIF: Cognitive Level: Apply
REF: p. 508
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
15. The nurse is providing support to parents at the time their child is diagnosed with chronic
disabilities. The nurse notices that the parents keep asking the same questions. What is the
nurse’s best intervention?
a. Patiently continue to answer questions.
b. Kindly refer them to someone else for answering their questions.
c. Recognize that some parents cannot understand explanations.
d. Suggest that they ask their questions when they are not upset.
ANS: A
Diagnosis is one of the anticipated stress points for parents. The parents may not hear or
remember all that is said to them. The nurse should continue to provide the kind of
information they desire. This is a particularly stressful time for the parents; the nurse can play
a key role in providing necessary information. Parents should be provided with oral and
written information. The nurse needs to work with the family to ensure understanding of the
information. The parents require information at the time of diagnosis. Other questions will
arise as they adjust to the information.
DIF: Cognitive Level: Apply
REF: p. 508
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
16. Which is the most appropriate nursing intervention to promote normalization in a school-age
child with a chronic illness?
Give the child as much control as possible.
Ask the child’s peer to make the child feel normal.
Convince the child that nothing is wrong with him or her.
Explain to parents that family rules for the child do not need to be the same as for
healthy siblings.
a.
b.
c.
d.
ANS: A
The school-age child who is ill may be forced into a period of dependency. To foster
normalcy, the child should be given as much control as possible. It is unrealistic to expect one
individual to make the child feel normal. The child has a chronic illness. It would be
unacceptable to convince the child that nothing is wrong. The family rules should be similar
for each of the children in a family. Resentment and hostility can arise if different standards
are applied to each child.
DIF: Cognitive Level: Apply
REF: p. 514
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
17. Which nursing intervention should the nurse include to help the siblings of a child with
special needs cope?
a. Explain to the siblings that embarrassment is unhealthy
b. Encourage the parents not to expect siblings to help them care for the child with
special needs
c. Provide information to the siblings about the child’s condition only as they request
it
d. Suggest to the parents ways of showing gratitude to the siblings who help care for
the child with special needs
ANS: D
The presence of a child with special needs in a family will change the family dynamic.
Siblings may be asked to take on additional responsibilities to help the parents to care for the
child. The parents should show gratitude, such as an increase in allowance, special privileges,
and verbal praise. Embarrassment may be associated with having a sibling with a chronic
illness or disability. Parents must be able to respond in an appropriate manner without
punishing the sibling. The parents may need assistance with the care of the child. Most
siblings are positive about the extra responsibilities. The siblings need to be informed about
the child’s condition before a nonfamily member does so. The parents do not want the
siblings to fantasize about what is wrong with the child.
DIF: Cognitive Level: Apply
REF: p. 514
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
18. The parents of a child born with disabilities ask the nurse for advice about discipline. What
information about disciple should the nurse’s response include?
a. It is essential for the child.
b. It is too difficult to implement with a special-needs child.
c. It is not needed unless the child becomes problematic.
d. It is best achieved with punishment for misbehavior.
ANS: A
Discipline is essential for the child. It provides boundaries on which to test out their behavior
and teaches them socially acceptable behaviors. The nurse should teach the parents ways to
manage the child’s behavior before it becomes problematic. Punishment is not effective in
managing behavior.
DIF: Cognitive Level: Understand
REF: p. 506
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
19. Kelly, an 8-year-old girl, will soon be able to return to school after an injury that resulted in
several severe, chronic disabilities. Which is the most appropriate action by the school nurse?
a. Recommend that the child’s parents attend school at first to prevent teasing.
b. Prepare the child’s classmates and teachers for changes they can expect.
c. Refer the child to a school where the children have chronic disabilities similar to
hers.
d. Discuss with the child and her parents the fact that her classmates will not accept
her as they did before.
ANS: B
Attendance at school is an important part of normalization for Kelly. The school nurse should
prepare teachers and classmates about her condition, abilities, and special needs. A visit by
the parents can be helpful, but unless the classmates are prepared for the changes, it alone
will not prevent teasing. Kelly’s school experience should be normalized as much as possible.
Children need the opportunity to interact with healthy peers, as well as to engage in activities
with groups or clubs composed of similarly affected persons. Children with special needs are
encouraged to maintain and reestablish relationships with peers and to participate according
to their capabilities.
DIF: Cognitive Level: Apply
REF: p. 507
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
20. A 16-year-old with a chronic illness has recently become rebellious and is taking risks such as
missing doses of his medication. What is the best explanation for this behavior?
a. Needs more discipline
b. Needs more socialization with peers
c. This is part of normal adolescence
d. This is how he is asking for more parental control
ANS: C
Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence.
DIF: Cognitive Level: Apply
REF: p. 510
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
21. Which term best describes a multidisciplinary approach to the management of a terminal
illness that focuses on symptom control and support?
Dying care
Curative care
Restorative care
Palliative care
a.
b.
c.
d.
ANS: D
This is one of the definitions of palliative care. The goal of palliative care is the achievement
of the highest possible quality of life for patients and their families.
DIF: Cognitive Level: Understand
REF: p. 518
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
22. Which best describes how preschoolers react to the death of a loved one?
a. A preschooler is too young to have a concept of death.
b. A preschooler may feel guilty and responsible for the death.
c. Grief is acute but does not last long at this age.
d. Grief is usually expressed in the same way in which the adults in the preschooler’s
life are expressing grief.
ANS: B
Because of egocentricity, the preschooler may feel guilty and responsible for the death.
DIF: Cognitive Level: Understand
REF: p. 521
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
23. A preschooler is found digging up a pet bird that was recently buried after it died. What is the
best explanation for this behavior?
Has a morbid preoccupation with death
Is looking to see whether a ghost took it away
The loss is not yet resolved, and professional counseling is needed
Reassurance is needed that the pet has not gone somewhere else
a.
b.
c.
d.
ANS: D
The preschooler can recognize that the pet has died but has difficulties with the permanence.
Digging up the bird gives reassurance that the bird is still present.
DIF: Cognitive Level: Understand
REF: p. 525
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
24. At what age do most children have an adult concept of death as being inevitable, universal,
and irreversible?
4 to 5 years
6 to 8 years
9 to 11 years
12 to 16 years
a.
b.
c.
d.
ANS: C
By age 9 to 11 years, children have an adult concept of death. They realize that it is
inevitable, universal, and irreversible.
DIF: Cognitive Level: Understand
REF: p. 521
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
25. Which is most descriptive of a school-age child’s reaction to death?
a. Is very interested in funerals and burials
b. Has little understanding of words such as forever
c. Imagines the deceased person to be still alive
d. Has an idealistic view of the world and criticizes funerals as barbaric
ANS: A
The school-age child is interested in post-death services and may be inquisitive about what
happens to the body.
DIF: Cognitive Level: Understand
REF: p. 521
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
26. At what developmental period do children have the most difficulty coping with death,
particularly if it is their own?
Toddlerhood
Preschool
School-age
Adolescence
a.
b.
c.
d.
ANS: D
Adolescents, because of their mature understanding of death, remnants of guilt and shame,
and issues with deviations from normal, have the most difficulty coping with death.
DIF: Cognitive Level: Understand
REF: p. 522
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
27. A school-age child is diagnosed with a life-threatening illness. The parents want to protect
their child from knowing the seriousness of the illness. What should the nurse tell the
parents?
a. This will help the child cope effectively by denial.
b. This attitude is helpful to give parents time to cope.
c. Terminally ill children know when they are seriously ill.
d. Terminally ill children usually choose not to discuss the seriousness of their illness.
ANS: C
The child needs honest and accurate information about the illness, treatments, and prognosis.
Children, even at a young age, realize that something is seriously wrong and that it involves
them. The nurse should help the parents understand the importance of honesty.
DIF: Cognitive Level: Analyze
REF: p. 526
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
28. A cure is no longer possible for a young child with cancer. The nursing staff recognizes that
the goal of treatment must shift from cure to palliation. Which is an important consideration
at this time?
a. The family is included in the decision to shift the goals of treatment.
b. The decision must be made by the health professionals involved in the child’s care.
c. The family needs to understand that palliative care takes place in the home.
d. The decision should not be communicated to the family because it will encourage a
sense of hopelessness.
ANS: A
When the child reaches the terminal stage, the nurse and physician should explore the
family’s wishes. The family should help decide what interventions will occur as they plan for
their child’s death.
DIF: Cognitive Level: Apply
REF: p. 518
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
29. The nurse is caring for a child who has just died. The parents ask to be left alone so that they
can rock their child one more time. What is the nurse’s most appropriate response?
Grant their request
Assess why they feel this is necessary
Discourage this because it will only prolong their grief
Kindly explain that they need to say good-bye to their child now and leave
a.
b.
c.
d.
ANS: A
The parents should be allowed to remain with their child after the death. The nurse can
remove all the tubes and equipment and offer the parents the option of preparing the body.
DIF: Cognitive Level: Apply
REF: p. 524
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
30. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still
“hear” the child’s voice and have trouble sleeping. They describe feeling “empty” and
depressed. How should the nurse interpret these feelings?
a. These are normal grief responses
b. The pain of the loss is usually less by this time
c. These grief responses are more typical of the early stages of grief
d. This grieving is essential until the pain is gone and the child is gradually forgotten.
ANS: A
These are normal grief responses. The process of grief work is lengthy.
DIF: Cognitive Level: Understand
REF: p. 525
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
31. At the time of a child’s death, the nurse tells his mother, “We will miss him so much.” What
is the best interpretation of this statement?
Pretending to be experiencing grief
Expressing personal feelings of loss
Denying the mother’s sense of loss
Talking when listening would be better
a.
b.
c.
d.
ANS: B
A patient’s death is one of the most stressful aspects of critical care or oncology nursing.
Nurses experience reactions similar to those of family members because of their involvement
with the child and family during the illness. Nurses often have feelings of personal loss when
a patient dies.
DIF: Cognitive Level: Analyze
REF: p. 525
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
32. Which is an appropriate nursing intervention when providing comfort and support for a child
when death is imminent?
a. Limit care to essentials.
b. Avoid playing music near the child.
c. Explain to the child the need for constant measurement of vital signs.
d. Whisper to the child instead of using a normal voice.
ANS: A
When death is imminent, care should be limited to interventions for palliative care.
DIF: Cognitive Level: Apply
REF: p. 526
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
33. The nurse is providing support to a family who is experiencing anticipatory grief related to
their child’s imminent death. Which of the following is an appropriate nursing intervention?
a. Be available to the family.
b. Attempt to “lighten the mood.”
c. Suggest activities to cheer up the family.
d. Discourage crying until actual time of death.
ANS: A
One of the most important nursing interventions of death is the availability of the nurse for
the family.
DIF: Cognitive Level: Apply
REF: p. 526
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
34. A new nurse is caring for a child who will require palliative care. Which statement made by
the new nurse would indicate a correct understanding of palliative care?
a. “Palliative care serves to hasten death and make the process easier for the family.”
b. “Palliative care provides pain and symptom management for the child.”
c. “The goal of palliative care is to place the child in a hospice setting at the end of
life.”
d. “The goal of palliative care is to act as the liaison between the family, child, and
other health care professionals.”
ANS: B
One of the goals of palliative care is to provide pain and symptom management.
DIF: Cognitive Level: Apply
REF: p. 520
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
35. Parents are asking about an early intervention program for their child who has special needs.
The nurse relates that this program is for which age of child?
a. Birth to 1 year of age
b. Birth to 3 years of age
c. Ages 1 to 4
d. Ages 4 and 5
ANS: B
A variety of supplemental programs have been designed in the school system to
accommodate special needs, both at school age and younger, through early intervention,
which consists of any sustained and systematic effort to assist children from birth to age 3
years with disabilities and those who are developmentally vulnerable.
DIF: Cognitive Level: Remember
REF: p. 503
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
36. A nurse is planning palliative care for a child with severe pain. Which should the nurse expect
to be prescribed for pain relief?
Opioids as needed
Opioids on a regular schedule
Distraction and relaxation techniques
Nonsteroidal anti-inflammatory drugs
a.
b.
c.
d.
ANS: B
Pain medications, for children in palliative care, should be given on a regular schedule, and
extra doses for breakthrough pain should be available to maintain comfort. Opioid drugs such
as morphine should be given for severe pain, and the dose should be increased as necessary to
maintain optimal pain relief. Techniques such as distraction, relaxation techniques, and
guided imagery should be combined with drug therapy to provide the child and family
strategies to control pain. Nonsteroidal anti-inflammatory drugs are not sufficient to manage
severe pain for children in palliative care.
DIF: Cognitive Level: Apply
REF: p. 523
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
37. The home health nurse is caring for a child who requires complex care. The family expresses
frustration related to obtaining accurate information about their child’s illness and its
management. Which is the best action for the nurse?
a. Determine why the family is easily frustrated.
b. Refer the family to the child’s primary care practitioner.
c. Clarify the family’s request, and provide the information they want.
d. Answer only questions that the family needs to know about.
ANS: C
The philosophic basis for family-centered practice is the recognition that the family is the
constant in the child’s life. It is essential and appropriate that the family have complete and
accurate information about their child’s illness and management. The nurse may first have to
clarify what information the family believes has not been communicated. The family’s
frustration arises from their perception that they are not receiving information pertinent to
their child’s care. Referring the family to the child’s primary care practitioner does not help
the family. The home health nurse should have access to the necessary information. Questions
about what they need and want to know concerning their child’s care should be addressed.
DIF: Cognitive Level: Apply
REF: p. 503
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
38. A mother of a 5-year-old child, with complex health care needs and cared for at home,
expresses anxiety about attending a kindergarten graduation exercise of a neighbor’s child.
The mother says, “I wish it could be my child graduating from kindergarten.” What should
the nurse recognize the mother is experiencing?
a. Abnormal anxiety
b. Ineffective coping
c. Chronic sorrow
d. Denial
ANS: C
Home care nurses should be aware that parents may experience chronic sorrow as a parental
stressor. Chronic sorrow as a normal grief response is associated with a living loss (the loss of
a healthy child) that is cyclical in nature. This is a normal response and does not indicate
abnormal anxiety, ineffective coping, or denial.
DIF: Cognitive Level: Understand
REF: p. 507
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. Which describes avoidance behaviors parents may exhibit when learning that their child has a
chronic condition? (Select all that apply.)
Refuses to agree to treatment
Shares burden of disorder with others
Verbalizes possible loss of child
Withdraws from outside world
Punishes self because of guilt and shame
a.
b.
c.
d.
e.
ANS: A, D, E
A parent who refuses to agree to treatment, withdraws from the outside world, and punishes
self because of guilt and shame is exhibiting avoidance coping behaviors. A parent who
shares the burden of disorder with others and verbalizes possible loss of child is exhibiting
approach coping behaviors.
DIF: Cognitive Level: Analyze
REF: p. 505
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
2. Which are appropriate statements the nurse should make to parents after the death of their
child? (Select all that apply.)
“We feel so sorry that we couldn’t save your child.”
“Your child isn’t suffering anymore.”
“I know how you feel.”
“You’re feeling all the pain of losing a child.”
“You are still young enough to have another baby.”
a.
b.
c.
d.
e.
ANS: A, D
By saying, “We feel so sorry that we couldn’t save your child,” the nurse is expressing
personal feeling of loss or frustration, which is therapeutic. Stating, “You’re feeling all the
pain of losing a child,” focuses on a feeling, which is therapeutic. The statement, “Your child
isn’t suffering anymore,” is a judgmental statement, which is nontherapeutic. “I know how
you feel” and “You’re still young enough to have another baby” are statements that give
artificial consolation and are nontherapeutic.
DIF: Cognitive Level: Apply
REF: p. 525
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
3. Which are adaptive coping patterns used by children with special needs? (Select all that
apply.)
Feels different and withdraws
Is irritable, moody, and acts out
Seeks support
Develops optimism
a.
b.
c.
d.
ANS: C, D
Adaptive coping patterns used by children with special needs include seeking support and
developing optimism. Maladaptive behaviors are seeing themselves as different and
withdrawing and becoming irritable, moody, and beginning to act out.
DIF: Cognitive Level: Understand
REF: p. 505
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
4. A child dependent on medical technology is preparing to be discharged from the hospital to
home. Which predischarge assessments should the nurse ensure? (Select all that apply.)
Emergency care and transport plan
Reliance on private duty nurses to teach the family infection control practices
Financial arrangements
Individualized home plan to be completed within the first month of the child’s
discharge
a.
b.
c.
d.
ANS: A, C
The predischarge plan for a child dependent on medical technology going home should
include emergency care and transport plan and financial arrangements. The infection control
practices and individualized home plan should be completed before discharge, not after the
child goes home.
DIF: Cognitive Level: Analyze
REF: p. 501
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a child who is near death. Which physical signs indicate the child is
approaching death? (Select all that apply.)
a. Body feels warm
b. Tactile sensation decreasing
c. Speech becomes rapid
d. Change in respiratory pattern
e. Difficulty swallowing
ANS: B, D, E
Physical signs of approaching death include: tactile sensation beginning to decrease, a change
in respiratory pattern, and difficulty swallowing. Even though there is a sensation of heat the
body feels cool, not warm, and speech becomes slurred, not rapid.
DIF: Cognitive Level: Understand
REF: p. 524
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
Chapter 18: Impact of Cognitive or Sensory Impairment on the Child and Family
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A young child has an intelligence quotient (IQ) of 45. The nurse should document this finding
as:
a.
b.
c.
d.
within the lower limits of the range of normal intelligence.
mild cognitive impairment but educable.
moderate cognitive impairment but trainable.
severe cognitive impairment and completely dependent on others for care.
ANS: C
Moderate cognitive impairment IQs range between 35 and 55. The lower limit of normal
intelligence is approximately 70. Individuals with IQs of 50 to 70 are considered to have mild
cognitive impairment but educable. An IQ of 20 to 40 results in severe cognitive impairment.
DIF: Cognitive Level: Understand
REF: p. 530
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
2. When a child with mild cognitive impairment reaches the end of adolescence, which
characteristic should be expected?
Achieves a mental age of 5 to 6 years
Achieves a mental age of 8 to 12 years
Unable to progress in functional reading or arithmetic
Acquires practical skills and useful reading and arithmetic to an eighth-grade level
a.
b.
c.
d.
ANS: B
By the end of adolescence, the child with mild cognitive impairment can acquire practical
skills and useful reading and arithmetic to a third- to sixth-grade level. A mental age of 8 to
12 years is obtainable, and the child can be guided toward social conformity. The
achievement of a mental age of 5 to 6 years and being unable to progress in functional
reading or arithmetic are characteristics of children with moderate cognitive impairment.
Acquiring practical skills and useful reading and arithmetic to an eighth-grade level is not
descriptive of cognitive impairment.
DIF: Cognitive Level: Understand
REF: p. 530
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
3. When should children with cognitive impairment be referred for stimulation and educational
programs?
As young as possible
As soon as they have the ability to communicate in some way
At age 3 years, when schools are required to provide services
At age 5 or 6 years, when schools are required to provide services
a.
b.
c.
d.
ANS: A
The child’s education should begin as soon as possible. Considerable evidence exists that
early intervention programs for children with disabilities are valuable for cognitively
impaired children. The early intervention may facilitate the child’s development of
communication skills. States are encouraged to provide early intervention programs from
birth under Public Law 101-476, the Individuals with Disabilities Education Act.
DIF: Cognitive Level: Apply
REF: p. 530
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
4. Which should be the major consideration when selecting toys for a child who is cognitively
impaired?
Safety
Age appropriateness
Ability to provide exercise
Ability to teach useful skills
a.
b.
c.
d.
ANS: A
Safety is the primary concern in selecting recreational and exercise activities for all children.
This is especially true for children who are cognitively impaired. Age appropriateness, the
ability to provide exercise, and the ability to teach useful skills should all be considered in the
selection of toys, but safety is of paramount importance.
DIF: Cognitive Level: Understand
REF: p. 531
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
5. What are appropriate interventions to facilitate socialization of the cognitively impaired
child?
a. Provide age-appropriate toys and play activities.
b. Provide peer experiences, such as scouting, when older.
c. Avoid exposure to strangers who may not understand cognitive development.
d. Emphasize mastery of physical skills because they are delayed more often than
verbal skills.
ANS: B
The acquisition of social skills is a complex task. Children of all ages need peer relationships.
Parents should enroll the child in preschool. When older, they should have peer experiences
similar to those of other children such as group outings, Boy and Girl Scouts, and Special
Olympics. It is important to provide age-appropriate toys and play activities, but peer
interactions will facilitate social development. Parents should expose the child to strangers so
that the child can practice social skills. Verbal skills are delayed more than physical skills.
DIF: Cognitive Level: Apply
REF: p. 533
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
6. The nurse is discussing sexuality with the parents of an adolescent girl with moderate
cognitive impairment. Which should the nurse consider when dealing with this issue?
a. Sterilization is recommended for any adolescent with cognitive impairment.
b. Sexual drive and interest are limited in individuals with cognitive impairment.
c. Individuals with cognitive impairment need a well-defined, concrete code of
sexual conduct.
d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is
sexually abused.
ANS: C
Adolescents with moderate cognitive impairment may be easily persuaded and lack
judgment. A well-defined, concrete code of conduct with specific instructions for handling
certain situations should be laid out for the adolescent. Permanent contraception by
sterilization presents moral and ethical issues and may have psychological effects on the
adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual
information regarding physical development and contraception. Cognitively impaired
individuals may desire to marry and have families. The adolescent needs to be protected from
individuals who may make intimate advances.
DIF: Cognitive Level: Apply
REF: p. 534
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
7. When caring for a newborn with Down syndrome, what should the nurse be aware is the most
common congenital anomaly associated with Down syndrome?
Hypospadias
Pyloric stenosis
Congenital heart disease
Congenital hip dysplasia
a.
b.
c.
d.
ANS: C
Congenital heart malformations, primarily septal defects, are the most common congenital
anomaly in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are
not frequent congenital anomalies associated with Down syndrome.
DIF: Cognitive Level: Understand
REF: p. 535
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular third-grade class for
part of the school day. His mother asks the school nurse about programs, such as Cub Scouts,
that he might join. The nurse’s recommendation should be based on which statement?
a. Programs like Cub Scouts are inappropriate for children who are cognitively
impaired.
b. Children with Down syndrome have the same need for socialization as other
children.
c. Children with Down syndrome socialize better with children who have similar
disabilities.
d. Parents of children with Down syndrome encourage programs, such as scouting,
because they deny that their children have disabilities.
ANS: B
Children of all ages need peer relationships. Children with Down syndrome should have peer
experiences similar to those of other children, such as group outings, Cub Scouts, and Special
Olympics. Programs such as Cub Scouts can help children with cognitive impairment
develop socialization skills. Although all children should have an opportunity to form a close
relationship with someone of the same developmental level, it is appropriate for children with
disabilities to develop relationships with children who do not have disabilities. The parents
are acting as advocates for their child.
DIF: Cognitive Level: Analyze
REF: p. 535
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
9. What is one of the major physical characteristics of the child with Down syndrome?
a. Excessive height
b. Spots on the palms
c. Inflexibility of the joints
d. Hypotonic musculature
ANS: D
Hypotonic musculature is one of the major characteristics. Children with Down syndrome
have short stature and a transverse palmar crease. Hyperflexibility is a characteristic of Down
syndrome.
DIF: Cognitive Level: Understand
REF: p. 535
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed
nasal bridge, protruding tongue, and transverse palmar creases. Of what are these findings
most suggestive?
a. Microcephaly
b. Down syndrome
c. Cerebral palsy
d. Fragile X syndrome
ANS: B
These are characteristics associated with Down syndrome. The infant with microcephaly has
a small head. Cerebral palsy is a diagnosis not usually made at birth. No characteristic
physical signs are present. The infant with fragile X syndrome has increased head
circumference; long, wide, and/or protruding ears; long, narrow face with prominent jaw;
hypotonia; and high arched palate.
DIF: Cognitive Level: Understand
REF: p. 535
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. The child with Down syndrome should be evaluated for which condition before participating
in some sports?
Hyperflexibility
Cutis marmorata
Atlantoaxial instability
Speckling of iris (Brushfield spots)
a.
b.
c.
d.
ANS: C
Children with Down syndrome are at risk for atlantoaxial instability. Before participating in
sports that put stress on the head and neck, a radiologic examination should be done.
Hyperflexibility, cutis marmorata, and speckling of iris (Brushfield spots) are characteristic of
Down syndrome, but they do not affect the child’s ability to participate in sports.
DIF: Cognitive Level: Understand
REF: p. 535
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. Many of the physical characteristics of Down syndrome present nursing problems. Care of
the child should include which intervention?
a. Delay feeding solid foods until the tongue thrust has stopped.
b. Modify diet as necessary to minimize the diarrhea that often occurs.
c. Provide calories appropriate to child’s age.
d. Use a cool-mist vaporizer to keep mucous membranes moist.
ANS: D
The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes
and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer
will keep the mucous membranes moist and liquefy secretions. The child has a protruding
tongue, which makes feeding difficult. The parents must persist with feeding while the child
continues the physiologic response of the tongue thrust. The child is predisposed to
constipation. Calories should be appropriate to the child’s weight and growth needs, not age.
DIF: Cognitive Level: Apply
REF: p. 535
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. A child has just been diagnosed with fragile X syndrome. What is fragile X syndrome?
a. A chromosomal defect affecting females only
b. A chromosomal defect that follows the pattern of X-linked recessive disorders
c. The second most common genetic cause of cognitive impairment
d. The most common cause of noninherited cognitive impairment
ANS: C
Fragile X syndrome is the second most common cause of cognitive impairment after Down
syndrome. Fragile X primarily affects males, and follows the inheritance pattern of X-linked
dominant with reduced penetrance. This is in distinct contrast to the classic X-linked
recessive pattern in which all carrier females are normal, all affected males have symptoms of
the disorder, and no males are carriers.
DIF: Cognitive Level: Remember
REF: p. 537
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. A school nurse is performing hearing screening on school children. The nurse recognizes that
distortion of sound and problems in discrimination are characteristic of which type of hearing
loss?
a. Conductive
b. Sensorineural
c. Mixed conductive-sensorineural
d. Central auditory imperceptive
ANS: B
Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to
the inner ear structures or the auditory nerve. It results in the distortion of sounds and
problems in discrimination. Conductive hearing loss involves mainly interference with
loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination
of both sensorineural and conductive loss. Central auditory imperceptive hearing loss
includes all hearing losses that do not demonstrate defects in the conduction or sensory
structures.
DIF: Cognitive Level: Understand
REF: p. 538
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Adaptation: Reduction of Risk Potential
15. A school nurse is performing hearing screening on school children. The nurse recognizes that
the most common type of hearing loss resulting from interference of transmission of sound to
the middle ear is characteristic of which type of hearing loss?
a. Conductive
b. Sensorineural
c. Mixed conductive-sensorineural
d. Central auditory imperceptive
ANS: A
Conductive or middle-ear hearing loss is the most common type. It results from interference
of transmission of sound to the middle ear, most often from recurrent otitis media.
Sensorineural, mixed conductive-sensorineural, and central auditory imperceptive are less
common types of hearing loss.
DIF: Cognitive Level: Understand
REF: p. 538
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. Hearing is expressed in decibels (dB), or units of loudness. Which is the softest sound a
normal ear can hear?
0 dB
10 dB
40 to 50 dB
100 dB
a.
b.
c.
d.
ANS: A
By definition, 0 dB is the softest sound the normal ear can hear. Ten decibels is the sound of
the heartbeat or the rustling of leaves. 40 to 50 dB is in the range of normal conversation. The
noise of a train is approximately 100 dB.
DIF: Cognitive Level: Understand
REF: p. 538
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. The nurse should suspect a hearing impairment in an infant who demonstrates which
behavior?
Absence of the Moro reflex
Absence of babbling by age 7 months
Lack of eye contact when being spoken to
Lack of gesturing to indicate wants after age 15 months
a.
b.
c.
d.
ANS: B
The absence of babbling or inflections in voice by age 7 months is an indication of hearing
difficulties. The absence of the Moro reflex and eye contact when being spoken to does not
indicate a hearing impairment. The child with hearing impairment uses gestures rather than
vocalizations to express desires at this age.
DIF: Cognitive Level: Apply
REF: p. 538
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing
aid is making an annoying whistling sound that the child cannot hear. Which is the most
appropriate nursing action?
a. Ignore the sound.
b. Ask him to reverse the hearing aids in his ears.
c. Suggest he reinsert the hearing aid.
d. Suggest he raise the volume of the hearing aid.
ANS: C
The whistling sound is acoustic feedback. The nurse should have the child remove the
hearing aid and reinsert it, making certain no hair is caught between the ear mold and the ear
canal. It would be annoying to others to ignore the sound or to suggest he raise the volume of
the hearing aid. The hearing aids are molded specifically for each ear.
DIF: Cognitive Level: Apply
REF: p. 540
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
19. Which is an implanted ear prosthesis for children with sensorineural hearing loss?
a. Hearing aid
b. Cochlear implant
c. Auditory implant
d. Amplification device
ANS: B
Cochlear implants are surgically implanted, and they provide a sensation of hearing for
individuals who have severe or profound hearing loss of sensorineural origin. Hearing aids
and amplification devices are external devices for enhancing hearing. Auditory implants do
not exist.
DIF: Cognitive Level: Understand
REF: p. 540
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. A nurse is caring for a hearing-impaired child who lip reads. The nurse should plan which
intervention to facilitate lipreading?
a. Speak at an even rate.
b. Exaggerate pronunciation of words.
c. Avoid using facial expressions.
d. Repeat in exactly the same way if the child does not understand.
ANS: A
The child should be helped to learn and understand how to read lips by speaking at an even
rate. It interferes with the child’s comprehension of the spoken word to exaggerate
pronunciation of words, to avoid using facial expressions, and to repeat in exactly the same
way if the child does not understand.
DIF: Cognitive Level: Apply
REF: p. 540
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
21. A nurse is preparing a teaching session for parents on prevention of childhood hearing loss.
What is the most common cause of hearing impairment in children?
a. Auditory nerve damage
b. Congenital ear defects
c. Congenital rubella
d. Chronic otitis media
ANS: D
Chronic otitis media is the most common cause of hearing impairment in children. It is
essential that appropriate measures be instituted to treat existing infections and prevent
recurrences. Auditory nerve damage, congenital ear defects, and congenital rubella are rarer
causes of hearing impairment.
DIF: Cognitive Level: Understand
REF: p. 542
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
22. Prevention of hearing impairment in children is a major goal for the nurse. This can be
achieved through which intervention?
Being involved in immunization clinics for children
Assessing a newborn for hearing loss
Answering parents’ questions about hearing aids
Participating in hearing screening in the community
a.
b.
c.
d.
ANS: A
Childhood immunizations can eliminate the possibility of acquired sensorineural hearing loss
from rubella, mumps, or measles encephalitis. Assessing a newborn for hearing loss,
answering parents’ questions about hearing aids, and participating in hearing screening in the
community are interventions to screen for the presence of hearing loss or deal with an
identified loss, not prevention.
DIF: Cognitive Level: Apply
REF: p. 542
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
23. Which term refers to the ability to see objects clearly at close range but not at a distance?
a. Myopia
b. Amblyopia
c. Cataract
d. Glaucoma
ANS: A
Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not at
distance. Amblyopia, or lazy eye, is reduced visual acuity in one eye. A cataract is opacity of
the lens of the eye. Glaucoma is a group of eye diseases characterized by increased
intraocular pressure.
DIF: Cognitive Level: Remember
REF: p. 542
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
24. Which of the following terms refers to opacity of the crystalline lens that prevents light rays
from entering the eye and refracting on the retina?
a. Myopia
b. Amblyopia
c. Cataract
d. Glaucoma
ANS: C
Opacity of the crystalline lens that prevents light rays from entering the eye and refracting on
the retina is the definition of a cataract. Myopia, or nearsightedness, refers to the ability to
see objects clearly at close range but not at a distance. Amblyopia, or lazy eye, is reduced
visual acuity in one eye. Glaucoma is a group of eye diseases characterized by increased
intraocular pressure.
DIF: Cognitive Level: Remember
REF: p. 543
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
25. A nurse should suspect possible visual impairment in a child who displays which
characteristic?
Excessive rubbing of the eyes
Rapid lateral movement of the eyes
Delay in speech development
Lack of interest in casual conversation with peers
a.
b.
c.
d.
ANS: A
Excessive rubbing of the eyes is a clinical manifestation of visual impairment. Rapid lateral
movement of the eyes, delay in speech development, and lack of interest in casual
conversation with peers are not associated with visual impairment.
DIF: Cognitive Level: Understand
REF: p. 543
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
26. When assessing the eyes of a neonate, the nurse observes opacity of the lens. This represents
which impairment?
a. Blindness
b. Glaucoma
c. Cataracts
d. Retinoblastoma
ANS: C
A cataract is opacity of the lens of the eye. The child may have visual impairment secondary
to the cataract, but the opacity is a cataract. Glaucoma is increased intraocular pressure.
Retinoblastoma is a tumor of the eye.
DIF: Cognitive Level: Understand
REF: p. 543
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
27. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment
includes which intervention?
a. Apply a regular eye patch.
b. Apply a Fox shield to affected eye and any type of patch to the other eye.
c. Apply ice until the physician is seen.
d. Irrigate eye copiously with a sterile saline solution.
ANS: B
The nurse’s role in a penetrating eye injury is to prevent further injury to the eye. A Fox
shield (if available) should be applied to the injured eye and a regular eye patch to the other
eye to prevent bilateral movement. It may cause more damage to the eye to apply a regular
eye patch, apply ice until the physician is seen, or irrigate the eye copiously with a sterile
saline solution.
DIF: Cognitive Level: Apply
REF: p. 544
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. A father calls the emergency department nurse saying that his daughter’s eyes burn after
getting some dishwasher detergent in them. The nurse recommends that the child be seen in
the emergency department or by an ophthalmologist. The nurse also should recommend
which action before the child is transported?
a. Keep eyes closed.
b. Apply cold compresses.
c. Irrigate eyes copiously with tap water for 20 minutes.
d. Prepare a normal saline solution (salt and water) and irrigate eyes for 20 minutes.
ANS: C
The first action is to flush the eyes with clean tap water. This will rinse the detergent from the
eyes. Keeping eyes closed and applying cold compresses may allow the detergent to do
further harm to the eyes during transport. Normal saline is not necessary. The delay can allow
the detergent to cause continued injury to the eyes.
DIF: Cognitive Level: Apply
REF: p. 544
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
29. An adolescent gets hit in the eye during a fight. The school nurse, using a flashlight, notes the
presence of gross hyphema (hemorrhage into anterior chamber). What is the priority nursing
action?
a. Apply a Fox shield
b. Instruct the adolescent to apply ice for 24 hours
c. Have the adolescent rest with eye closed and ice applied
d. Notify parents that the adolescent needs to see an ophthalmologist
ANS: D
The parents should be notified that the adolescent needs to see an ophthalmologist as soon as
possible. Applying a Fox shield, instructing the adolescent to apply ice for 24 hours, and
having the adolescent rest with eye closed and ice applied may cause further damage.
Referral to an ophthalmologist is indicated.
DIF: Cognitive Level: Apply
REF: p. 544
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. Which of the following is the most common clinical manifestation of retinoblastoma?
a. Glaucoma
b. Amblyopia
c. Cat’s eye reflex
d. Sunken eye socket
ANS: C
When the eye is examined, the light will reflect off the tumor, giving the eye a whitish
appearance. This is called a cat’s eye reflex. A late sign of retinoblastoma is a red, painful eye
with glaucoma. Amblyopia, or lazy eye, is reduced visual acuity in one eye. The eye socket is
not sunken.
DIF: Cognitive Level: Understand
REF: p. 542
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. The nurse is talking to the parent of a 13-month-old child. The mother states, “My child does
not make noises like ‘da’ or ‘na’ like my sister’s baby, who is only 9 months old.” Which
statement by the nurse would be most appropriate to make?
a. “I am going to request a referral to a hearing specialist.”
b. “You should not compare your child to your sister’s child.”
c. “I think your child is fine, but we will check again in 3 months.”
d. “You should ask other parents what noises their children made at this age.”
ANS: A
By 11 months of age a child should be making well-formed syllables such as “da” or “na”
and should be referred to a specialist if not. “You should not compare your child to your
sister’s child,” “I think your child is fine, but we will check again in 3 months,” and “You
should ask other parents what noises their children made at this age,” are not appropriate
statements to make to the parent.
DIF: Cognitive Level: Analyze
REF: p. 540
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
32. A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive
impairment (CI) who sustained a minor burn. Which strategy should the nurse use to prepare
the child for this procedure?
a. Verbally explain what will be done.
b. Have the child watch a video on dressing changes.
c. Demonstrate a dressing change on a doll.
d. Explain the importance of keeping the burn area clean.
ANS: C
Children with CI have a marked deficit in their ability to discriminate between two or more
stimuli because of difficulty in recognizing the relevance of specific cues. However, these
children can learn to discriminate if the cues are presented in an exaggerated, concrete form
and if all extraneous stimuli are eliminated. Therefore, demonstration is preferable to verbal
explanation, and learning should be directed toward mastering a skill rather than
understanding the scientific principles underlying a procedure. Watching a video would
require the use of both visual and auditory stimulation and might produce overload in the
child with mild cognitive impairment. Explaining the importance of keeping the burn area
clean would be too abstract for the child.
DIF: Cognitive Level: Apply
REF: p. 530
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
33. Parents of a child with Down syndrome ask the nurse about techniques for introducing solid
food to their 8-month-old child’s diet. The nurse should give the parents which priority
instruction?
a. It is too early to add solids; the parents should wait for 2 to 3 months.
b. A small but long, straight-handled spoon should be used to push the food toward
the back and side of the mouth.
c. If the child thrusts the food out, the feeding should be stopped.
d. Solids should be offered only three times a day.
ANS: B
Down syndrome children have a protruding tongue which can interfere with feeding,
especially of solid foods. Parents need to know that the tongue thrust is not an indication of
refusal to feed but a physiologic response. Parents are advised to use a small but long,
straight-handled spoon to push the food toward the back and side of the mouth. If food is
thrust out, it should be re-fed. Six months is the time to introduce solid foods to a child, so
waiting 2 to 3 months is inappropriate. Small frequent feedings should be initiated to prevent
the child from tiring. Three times a day is too infrequent.
DIF: Cognitive Level: Apply
REF: p. 535
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
34. A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The
nurse should plan which priority intervention when caring for the child?
Maintain a structured routine and keep stimulation to a minimum.
Place child in a room with a roommate of the same age.
Maintain frequent touch and eye contact with the child.
Take the child frequently to the playroom to play with other children.
a.
b.
c.
d.
ANS: A
Providing a structured routine for the child to follow is a key in the management of ASD.
Decreasing stimulation by using a private room, avoiding extraneous auditory and visual
distractions, and encouraging the parents to bring in possessions the child is attached to may
lessen the disruptiveness of hospitalization. Because physical contact often upsets these
children, minimum holding and eye contact may be necessary to avoid behavioral outbursts.
Children with ASD need to be introduced slowly to new situations, with visits with staff
caregivers kept short whenever possible. The playroom would be too overwhelming with new
people and situations and should not be a priority of care.
DIF: Cognitive Level: Apply
REF: p. 547
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
35. Which genetic term refers to the transfer of all or part of a chromosome to a different
chromosome after chromosome breakage?
a. Trisomy
b. Monosomy
c. Translocation
d. Nondisjunction
ANS: C
A translocation occurs when a part of a chromosome breaks off and attaches to another
chromosome. When this occurs in the germ cells, the translocation can be transmitted to the
next generation. Trisomy is the condition in which three of a specific chromosome are found
rather than the usual two. Monosomy is the condition in which one of a specific chromosome
is noted rather than the usual two. The term is not used for males when the normal
complement of sex chromosomes (one X and one Y) is present. Nondisjunction is the failure
of a chromosome to separate during cell division. Of the resultant daughter cells, one will be
trisomic and one will be monosomic.
DIF: Cognitive Level: Understand
REF: p. 535
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
36. Trisomy 13, trisomy 18, and trisomy 21 have which in common?
a. Viability is rare.
b. They are considered deletion syndromes.
c. Diagnosis is difficult, time-consuming, and expensive.
d. Diagnosis can be made early, based on physical characteristics.
ANS: D
Each of these disorders, trisomy 13, 18, and 21, has unique physical characteristics. A
presumptive diagnosis can often be made soon after birth and later confirmed by
chromosomal analysis. Children with trisomy 13 and 18 usually have short life expectancies.
Trisomy 21 has a variable life expectancy, with 80% of individuals living to age 30 years.
Trisomy 13, trisomy 18, and trisomy 21 are not deletion syndromes.
DIF: Cognitive Level: Understand
REF: p. 537
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. Autism is a complex developmental disorder. The diagnostic criteria for autism include
delayed or abnormal functioning in which areas with onset before age 3 years? (Select all
that apply.)
a. Language as used in social communication
b. Parallel play
c. Gross motor development
d. Growth below the 5th percentile for height and weight
e. Symbolic or imaginative play
f. Social interaction
ANS: A, E, F
These are three of the areas in which autistic children may show delayed or abnormal
functioning: language as used in social communication, symbolic or imaginative play, and
social interaction. Parallel play is typical play of toddlers and is usually not affected. Gross
motor development and growth below the 5th percentile for height and weight are usually not
characteristic of autism.
DIF: Cognitive Level: Analyze
REF: p. 547
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which assessment findings indicate to the nurse a child has Down syndrome? (Select all that
apply.)
High arched narrow palate
Protruding tongue
Long, slender fingers
Transverse palmar crease
Hypertonic muscle tone
a.
b.
c.
d.
e.
ANS: A, B, D
The assessment findings of Down syndrome include high arched narrow palate, protruding
tongue, and transverse palmar creases. The fingers are stubby and the muscle tone is
hypotonic, not hypertonic.
DIF: Cognitive Level: Understand
REF: p. 535
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. A nurse is instructing a nursing assistant on techniques to facilitate lipreading with a hearing-
impaired child who lip reads. Which techniques should the nurse include? (Select all that
apply.)
a. Speak at eye level.
b. Stand at a distance from the child.
c. Speak words in a loud tone.
d. Use facial expressions while speaking.
e. Keep sentences short.
ANS: A, D, E
To facilitate lipreading for a hearing-impaired child who can lip read, the speaker should be at
eye level, facing the child directly or at a 45-degree angle. Facial expressions should be used
to assist in conveying messages, and the sentences should be kept short. The speaker should
stand close to the child, not at a distance, and using a loud tone while speaking will not
facilitate lipreading.
DIF: Cognitive Level: Apply
REF: p. 547
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care: Management
Chapter 19: Family-Centered Care of the Child During Illness and Hospitalization
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for four patients; three are toddlers and one is a preschooler. Which represents
the major stressor of hospitalization for these four patients?
a.
Separation anxiety
b.
Loss of control
c.
Fear of bodily injury
d.
Fear of pain
ANS: A
The major stressor for children from infancy through the preschool years is separation anxiety,
also called anaclitic depression. This is a major stressor of hospitalization. Loss of control, fear
of bodily injury, and fear of pain are all stressors associated with hospitalization. However, separation from family is a primary stressor in this age group.
DIF: Cognitive Level: Analyze
REF: p. 554
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
2. During the first 4 days of hospitalization, Eric, age 18 months, cried inconsolably when his par-
ents left him, and he refused the staff’s attention. Now the nurse observes that Eric appears to be
“settled in” and unconcerned about seeing his parents. The nurse should interpret this as which
statement?
a.
He has successfully adjusted to the hospital
environment.
b.
He has transferred his trust to the nursing
staff.
c.
He may be experiencing detachment, which is
the third stage of separation anxiety.
d.
Because he is “at home” in the hospital now,
seeing his mother frequently will only start
the cycle again.
ANS: C
Detachment is a behavior manifestation of separation anxiety. Superficially it appears that the
child has adjusted to the loss. Detachment is a sign of resignation, not contentment. Parents
should be encouraged to be with their child. If parents restrict visits, they may begin a pattern of
misunderstanding the child’s cues and not meeting his needs.
DIF: Cognitive Level: Analyze
REF: p. 554
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
3. When a preschool child is hospitalized without adequate preparation, how does the child often
react to the hospitalization?
a.
b.
c.
d.
Sees it as a punishment
A threat to child’s self-image
An opportunity for regression
Loss of companionship with friends
ANS: A
If a toddler is not prepared for hospitalization, a typical preschooler fantasy is to attribute the
hospitalization to punishment for real or imagined misdeeds. Attributing the hospitalization to
punishment for real or imagined misdeeds is a reaction typical of toddler and school-age children
when threatened with loss of control.
DIF: Cognitive Level: Understand
REF: p. 554
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which age group should the pediatric nurse recognize as being vulnerable to events that lessen
their feeling of control and power?
a.
b.
c.
d.
Infants
Toddlers
Preschoolers
School-age children
ANS: D
When a child is hospitalized, the altered family role, physical disability, loss of peer acceptance,
lack of productivity, and inability to cope with stress usurp individual power and identity. This is
especially detrimental to school-age children, who are striving for independence and productivity
and are now experiencing events that lessen their control and power. Infants, toddlers, and
preschoolers, although affected to different extents by loss of power, are not as significantly affected as are school-age children.
DIF: Cognitive Level: Understand
REF: p. 556
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
5. A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the
nurse, “Wait a minute” and “I’m not ready.” The nurse should recognize this as which description?
a.
This is normal behavior for a school-age
child.
b.
The behavior is not seen past the preschool
years.
c.
The child thinks the nurse is punishing her.
d.
The child has successfully manipulated the
nurse in the past.
ANS: A
The 10-year-old girl is attempting to maintain control. The nurse should provide the girl with
structured choices about when the IV will be inserted. Telling the nurse “Wait a minute” and
“I’m not ready” can be characteristic behavior when an individual needs to maintain some control over a situation.
DIF: Cognitive Level: Analyze
REF: p. 562
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. What is a common initial reaction of parents to illness or injury and hospitalization in their child?
a.
Anger
b.
Fear
c.
Depression
d.
Helplessness
ANS: D
Recent research has identified common themes among parents whose children were hospitalized,
including feeling an overall sense of helplessness, questioning the skills of staff, accepting the reality of hospitalization, needing to have information explained in simple language, dealing with
fear, coping with uncertainty, and seeking reassurance from caregivers. Anger or guilt is usually
the second reaction stage. Fear, anxiety, and frustrations also are common feelings. Parents may
finally react with some form of depression related to the physical and emotional exhaustion associated with a hospitalized child.
DIF: Cognitive Level: Understand
REF: p. 557
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
7. Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse
overhears her school-age siblings tell her, “We are sick of Mom always sitting with you in the
hospital and playing with you. It isn’t fair that you get everything and we have to stay with the
neighbors.” Which is the nurse’s best assessment of this situation?
a.
The siblings are immature and probably
spoiled.
b.
Jealousy and resentment are common reactions to the illness or hospitalization of a sib
ling.
c.
d.
Family has ineffective coping mechanisms to
deal with chronic illness.
The siblings need to better understand their
sister’s illness and needs.
ANS: B
Siblings experience loneliness, fear, and worry, as well as anger, resentment, jealousy, and guilt.
The siblings experience stress equal to that of the hospitalized child. There is no evidence that
the family has maladaptive coping mechanisms.
DIF: Cognitive Level: Analyze
REF: p. 568
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
8. What is an appropriate nursing intervention to minimize separation anxiety in a hospitalized tod-
dler?
a.
b.
c.
d.
Provide for privacy
Encourage parents to room in
Explain procedures and routines
Encourage contact with children the same age
ANS: B
A toddler experiences separation anxiety secondary to being separated from the parents. To avoid
this, the parents should be encouraged to room in as much as possible. Maintaining routines and
ensuring privacy are helpful interventions, but they would not substitute for the parents. Encouraging contact with children the same age would not substitute for having the parents present.
DIF: Cognitive Level: Apply
REF: p. 557
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Four-year-old Brian appears to be upset by hospitalization. Which is an appropriate intervention?
a.
Let him know it is all right to cry.
b.
Give him time to gain control of himself.
c.
Show him how other children are cooperatd.
ing.
Tell him what a big boy he is to be so quiet.
ANS: A
Crying is an appropriate behavior for the upset preschooler. The nurse provides support through
physical presence. Giving the child time to gain control is appropriate, but the child must know
that crying is acceptable. The preschooler does not engage in competitive behaviors.
DIF: Cognitive Level: Apply
REF: p. 556
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Latasha, age 8 years, is being admitted to the hospital from the emergency department with an in-
jury from falling off her bicycle. Which will help her most in her adjustment to the hospital?
a.
b.
c.
d.
Explain hospital schedules to her, such as
mealtimes.
Use terms such as “honey” and “dear” to
show a caring attitude.
Explain when parents can visit and why siblings cannot come to see her.
Orient her parents, because she is young, to
her room and hospital facility.
ANS: A
School-age children need to have control of their environment. The nurse should offer explanations or prepare the child for those experiences that are unavailable. The nurse should refer to the
child by the preferred name. Explaining when parents can visit and why siblings cannot come to
see her is telling the child all of the limitations, not helping her adjust to the hospital. At the age
of 8 years, the child should be oriented to the environment along with the parents.
DIF: Cognitive Level: Apply
REF: p. 556
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Samantha, age 5 years, tells the nurse that she “needs a Band-Aid” where she had an injection.
Which is the best nursing action?
a.
b.
c.
d.
Apply a Band-Aid.
Ask her why she wants a Band-Aid.
Explain why a Band-Aid is not needed.
Show her that the bleeding has already
stopped.
ANS: A
Children at this age group still fear that their insides may leak out at the injection site. Provide
the Band-Aid. No explanation should be required. The nurse should be prepared to apply a small
Band-Aid after the injection.
DIF: Cognitive Level: Apply
REF: p. 563
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
12. Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the
nurse that they are going to buy her “a lot of new toys, because she will be in the hospital.” The
nurse’s reply should be based on an understanding of which concept?
a.
New toys make hospitalization easier.
b.
New toys are usually better than older ones
for children of this age.
c.
At this age, children often need the comfort
and reassurance of familiar toys from home.
d.
Buying new toys for a hospitalized child is a
maladaptive way to cope with parental guilt.
ANS: C
Parents should bring favorite items from home to be with the child. Young children associate
inanimate objects with people who are significant in their lives. The favorite items will comfort
and reassure the child. Because the parents left the objects, the preschooler knows the parents
will return. New toys will not serve the purpose of familiar toys and objects from home. The parents may experience some guilt as a response to the hospitalization, but there is no evidence that
it is maladaptive.
DIF: Cognitive Level: Apply
REF: p. 565
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
13. Matthew, age 18 months, has just been admitted with croup. His parent is tearful and tells the
nurse, “This is all my fault. I should have taken him to the doctor sooner so he wouldn’t have to
be here.” Which is appropriate in the care plan for this parent who is experiencing guilt?
a.
Clarify misconception about the illness.
b.
Explain to the parent that the illness is not se
rious.
c.
Encourage the parent to maintain a sense of
control.
d.
Assess further why the parent has excessive
guilt feelings.
ANS: A
Guilt is a common response of parents when a child is hospitalized. They may blame themselves
for the child’s illness or for not recognizing it soon enough. The nurse should clarify the nature
of the problem and reassure parents that the child is being cared for. Croup is a potentially serious illness. The nurse should not minimize the parent’s feelings. It would be difficult for the parent to maintain a sense of control while the child is seriously ill. No further assessment is indicated at this time; guilt is a common response for parents.
DIF: Cognitive Level: Analyze
REF: p. 567
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
14. A 14-year-old boy is being admitted to the hospital for an appendectomy. Which roommate
should the nurse assign with this patient?
a.
b.
c.
d.
A 4-year-old boy post-appendectomy surgery
A 6-year-old boy with pneumonia
A 15-year-old boy admitted with a vasoocclu
sive sickle cell crisis
A 12-year-old boy with cellulitis
ANS: C
When a child is admitted, nurses follow several fairly universal admission procedures. The minimum considerations for room assignment are age, sex, and nature of the illness. Age grouping is
especially important for adolescents. The 14-year-old boy being admitted to the unit after appendectomy surgery should be placed with a noninfectious child of the same sex and age. The 15year-old child with sickle cell is the best choice. The 4-year-old post-appendectomy is too young,
and the child with pneumonia is too young and possibly has an infectious process. The 12-year-
old boy with cellulitis is the right age, but he has an infection (cellulitis).
DIF: Cognitive Level: Apply
REF: p. 567
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
15. The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture
of the wrist during a bicycle accident. Which statement by the adolescent should be expected
about separation anxiety?
a.
“I wish my parents could spend the night with
me while I am in the hospital.”
b.
“I think I would like for my siblings to visit
me but not my friends.”
c.
“I hope my friends don’t forget about visiting
me.”
d.
“I will be embarrassed if my friends come to
the hospital to visit.”
ANS: C
Loss of peer-group contact may pose a severe emotional threat to an adolescent because of loss
of group status, so friends visiting are an important aspect of hospitalization for an adolescent.
Most adolescents do not need a parent to spend the night during hospitalization and sometimes
view the hospitalization as a welcome event. Adolescents would be more concerned about
friends visiting than siblings. Adolescents want visitors to keep control and maintain social status
among their group of peers.
DIF: Cognitive Level: Analyze
REF: p. 556
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A nurse is preparing to complete an admission assessment on a 2-year-old child. The child is sit-
ting on the parent’s lap. Which technique should the nurse implement to complete the physical
exam?
a.
Ask the parent to place the child in the hospi
tal crib.
b.
Take the child and parent to the exam room.
c.
Perform the exam while the child is on the
parent’s lap.
d.
Ask the child to stand by the parent while
completing the exam.
ANS: C
The nurse should complete the exam while the child is on the parent’s lap. For young children,
particularly infants and toddlers, preserving parent–child contact is the best means of decreasing
the need for or stress of restraint. The entire physical examination can be done in a parent’s lap
with the parent hugging the child for procedures such as an otoscopic examination. Placing the
child in the crib, taking the child to the exam room, or asking the child to stand by the parent
would separate the child from the parent and cause anxiety.
DIF: Cognitive Level: Apply
REF: p. 562
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
17. A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports diffi-
culty in going to sleep at night. Which intervention should the nurse implement to assist the child
in going to sleep at bedtime?
a.
Request a prescription for a sleeping pill.
b.
Allow the child to stay up late and sleep late
in the morning.
c.
Create a schedule similar to the one the child
follows at home.
d.
Plan passive activities in the morning and in
teractive activities right before bedtime.
ANS: C
Many children obtain significantly less sleep in the hospital than at home; the primary causes are
a delay in sleep onset and early termination of sleep because of hospital routines. One technique
that can minimize the disruption in the child’s routine is establishing a daily schedule. This approach is most suitable for non–critically ill school-age and adolescent children who have mastered the concept of time. It involves scheduling the child’s day to include all those activities that
are important to the child and nurse, such as treatment procedures, schoolwork, exercise, television, playroom, and hobbies. The school-age child with osteomyelitis would benefit from a
schedule similar to the one followed at home. Requesting a prescription for a sleeping pill would
be inappropriate and allowing the child to stay up late and sleep late would not be keeping the
child in a routine followed at home. Passive activities in the morning and interactive activities at
bedtime should be reversed; it would be better to keep the child active in the morning hours and
plan quiet activities at bedtime.
DIF: Cognitive Level: Apply
REF: p. 562
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. A previously “potty-trained” 30-month-old child has reverted to wearing diapers while hospital-
ized. The nurse should reassure the parents that this is normal because of which reason?
a.
Regression is seen during hospitalization.
b.
Developmental delays occur because of the
hospitalization.
c.
The child is experiencing urinary urgency be
cause of hospitalization.
d.
The child was too young to be “pottytrained.”
ANS: A
Regression is expected and normal for all age groups when hospitalized. Nurses should assure
the parents this is temporary and the child will return to the previously mastered developmental
milestone when back home. This does not indicate a developmental delay. The child should not
be experiencing urinary urgency because of hospitalization and this would not be normal. Suc-
cessful “potty-training” can be started at 2 years of age if the child is ready.
DIF: Cognitive Level: Apply
REF: p. 564
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
19. A child is playing in the playroom. The nurse needs to obtain a child’s blood pressure. Which is
the appropriate procedure for obtaining the blood pressure?
Take the blood pressure in the playroom.
Ask the child to come to the exam room to
obtain the blood pressure.
c.
Ask the child to return to his or her room for
the blood pressure, then escort the child back
to the playroom.
d.
Document that the blood pressure was not ob
tained because the child was in the playroom.
a.
b.
ANS: C
The play room is a safe haven for children, free from medical or nursing procedures. The child
can be returned to his or her room for the blood pressure and then escorted back to the playroom.
The exam room is reserved for painful procedures that should not be performed in the child’s
hospital bed. Documenting that the blood pressure was not obtained because the child was in the
playroom is inappropriate.
DIF: Cognitive Level: Apply
REF: p. 566
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
20. A nurse in the emergency department is assessing a 5-year-old child with symptoms of pneumo-
nia and a fever of 102° F. Which intervention can the nurse implement to promote a sense of control for the child?
a.
None; this is an emergency and the child
should not participate in care.
b.
Allow the child to hold the digital thermome
ter while taking the child’s blood pressure.
c.
Ask the child if it is OK to take a temperature
in the ear.
d.
Have parents wait in the waiting room.
ANS: B
The nurse should allow the child to hold the digital thermometer while taking the child’s blood
pressure. Unless an emergency is life threatening, children need to participate in their care to
maintain a sense of control. Because emergency departments are frequently hectic, there is a tendency to rush through procedures to save time. However, the extra few minutes needed to allow
children to participate may save many more minutes of useless resistance and uncooperativeness
during subsequent procedures. The child may not give permission, if asked, for a procedure that
is necessary to be performed. It is better to give choices such as, “Which ear do you want me to
do your temperature in?” instead of, “Can I take your temperature?” Parents should remain with
their child to help with decreasing the child’s anxiety.
DIF: Cognitive Level: Apply
REF: p. 571
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
21. Which is an effective strategy to reduce the stress of burn dressing procedures?
a.
Give the child as many choices as possible.
b.
Reassure the child that dressing changes are
c.
d.
not painful.
Explain to the child why analgesics cannot be
used.
Encourage the child to master stress with con
trolled passivity.
ANS: A
Children who understand the procedure and have some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many
choices as possible. The dressing change procedure is painful and stressful. Misinformation
should not be given to the child. Analgesia and sedation can and should be used. Encouraging the
child to master stress with controlled passivity is not a positive coping strategy.
DIF: Cognitive Level: Apply
REF: p. 572
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
22. Which is an important consideration for the nurse when changing dressings and applying topical
medication to a child’s abdomen and leg burns?
Apply topical medication with clean hands.
Wash hands and forearms before and after
dressing change.
c.
If dressings adhere to the wound, soak in hot
water before removal.
d.
Apply dressing so that movement is limited
during the healing process.
a.
b.
ANS: B
Frequent hand and forearm washing is the single most important element of the infection-control
program. Topical medications should be applied with a tongue blade or gloved hand. Dressings
that have adhered to the wound can be removed with tepid water or normal saline. Dressings are
applied with sufficient tension to remain in place but not so tightly as to impair circulation or
limit motion.
DIF: Cognitive Level: Apply
REF: p. 562
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. A nurse is admitting a toddler to the hospital. The parent needs to leave for a brief period. Which
figure depicts the reaction the nurse expects from the child?
a.
b.
c.
d.
ANS: A
The major stress from middle infancy throughout the preschool years, especially for children
ages 6 to 30 months, is separation anxiety, also called anaclitic depression. During the stage of
protest, children react aggressively to the separation from the parent. They cry and scream for
their parents, refuse the attention of anyone else, and are inconsolable in their grief. When the
parent leaves even for a short time this is the expected reaction and the figure that depicts the
child not wanting the parent to leave is what the nurse should expect as a reaction from the child.
The child sitting alone sadly depicts a child in the despair stage. In this stage depression is evident. The child is much less active, is uninterested in play or food, and withdraws from others.
The child sitting on the parent’s lap is withdrawn and sad, even in the presence of the parent. The
child depicted playing a game is adjusting to the hospitalization with play.
DIF: Cognitive Level: Analyze
REF: p. 554
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. A child has just been unexpectedly admitted to the intensive care unit after abdominal surgery.
The nursing staff has completed the admission process, and the child’s condition is beginning to
stabilize. When speaking with the parents, the nurses should expect which stressors to be evident? (Select all that apply.)
a.
Unfamiliar environment
b.
Usual day-night routine
c.
Strange smells
d.
Provision of privacy
e.
Inadequate knowledge of condition and routine
ANS: A, C, E
Intensive care units, especially when the family is unprepared for the admission, are a strange
and unfamiliar place with many pieces of unfamiliar equipment. The sights and sounds are much
different from those of a general hospital unit. Also, with the child’s condition being more precarious, it may be difficult to keep the parents updated and knowledgeable about what is happening. Lights are usually on around the clock, seriously disrupting the diurnal rhythm. There is usually little privacy available for families in intensive care units.
DIF: Cognitive Level: Understand
REF: p. 554
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
2. A nurse plans therapeutic play time for a hospitalized child. What are the benefits of play? (Se-
lect all that apply.)
a.
Serves as method to assist disturbed children
b.
c.
d.
e.
Allows the child to express feelings
The nurse can gain insight into the child’s
feelings.
The child can deal with concerns and feelings.
Gives the child a structured play environment
ANS: B, C, D
Play is an effective, nondirective modality for helping children deal with their concerns and
fears, and at the same time, it often helps the nurse gain insights into children’s needs and feelings. Play and other expressive activities provide one of the best opportunities for encouraging
emotional expression, including the safe release of anger and hostility. Nondirective play that allows children freedom for expression can be tremendously therapeutic. Play therapy is a structured therapy that helps disturbed children. It should not be confused with therapeutic play.
DIF: Cognitive Level: Understand
REF: p. 565
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
3. A child is being discharged from an ambulatory care center after an inguinal hernia repair. Which
discharge interventions should the nurse implement? (Select all that apply.)
a.
Discuss dietary restrictions.
b.
Hold any analgesic medications until the
child is home.
c.
Send a pain scale home with the family.
d.
Suggest the parents fill the prescriptions on
the way home.
e.
Discuss complications that may occur.
ANS: A, C, E
The discharge interventions a nurse should implement when a child is being discharged from an
ambulatory care center should include dietary restrictions, being very specific and giving examples of “clear fluids” or what is meant by a “full liquid diet.” The nurse should give specific information on pain control and send a pain scale home with the family. All complications that may
occur after an inguinal hernia repair should be discussed with the parents. The pain medication,
as prescribed, should be given before the child leaves the building and prescriptions should be
filled and given to the family before discharge.
DIF: Cognitive Level: Apply
REF: p. 570
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A child is being admitted to the intensive care unit (ICU) and the parents are with the child.
Which creates stressors for children and parents in ICUs? (Select all that apply.)
Equipment noise
Privacy
Caring behavior by the nurse
Unfamiliar smells
a.
b.
c.
d.
e.
Sleep deprivation
ANS: A, D, E
The ICU can create physical and environmental stressors for children and their families. Equipment noise (monitors, suction equipment, telephones, computers), unfamiliar smells (alcohol, adhesive remover, body odors), and sleep deprivation all are stressors found in the ICU. Privacy as
opposed to no privacy and a caring nurse as opposed to unkind or thoughtless comments from
staff help reduce the stressors of the ICU.
DIF: Cognitive Level: Understand
REF: p. 572
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
5. A nurse is interviewing the parents of a toddler about use of complementary or alternative medi-
cal practices. The parents share several practices they use in their household. Which should the
nurse document as complementary or alternative medical practices? (Select all that apply.)
a.
Use of acetaminophen (Tylenol) for fever
b.
Administration of chamomile tea at bedtime
c.
Hypnotherapy for relief of pain
d.
Acupressure to relieve headaches
e.
Cool mist vaporizer at the bedside for “stuffi
ness”
ANS: B, C, D
When conducting an assessment, the nurse should inquire about the use of complementary or alternative medical practices. Administration of chamomile tea at bedtime, hypnotherapy for relief
of pain, and acupressure to relieve headaches are complementary or alternative medical practices. Using Tylenol for fever relief and a cool mist vaporizer at the bedside to reduce “stuffiness” are not considered complementary or alternative medical practices.
DIF: Cognitive Level: Understand
REF: p. 560
TOP: Integrated Process: Nursing Process: Assessment
Chapter 20: Pediatric Variations of Nursing Interventions
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which should the nurse consider when having consent forms signed for surgery and
procedures on children?
a. Only a parent or legal guardian can give consent.
b. The person giving consent must be at least 18 years old.
c. The risks and benefits of a procedure are part of the consent process.
d. A mental age of 7 years or older is required for a consent to be considered
“informed.”
ANS: C
The informed consent must include the nature of the procedure, benefits and risks, and
alternatives to the procedure. In special circumstances, such as emancipated minors, the
consent can be given by someone younger than 18 years without the parent or legal guardian.
A mental age of 7 years is too young for consent to be informed.
DIF: Cognitive Level: Understand
REF: p. 575
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
2. The nurse is planning to prepare a 4-year-old child for some diagnostic procedures.
Guidelines for preparing this preschooler should include which action?
Plan for a short teaching session of about 30 minutes.
Tell the child that procedures are never a form of punishment.
Keep equipment out of the child’s view.
Use correct scientific and medical terminology in explanations.
a.
b.
c.
d.
ANS: B
Illness and hospitalization may be viewed as punishment in preschoolers. Always state
directly that procedures are never a form of punishment. Teaching sessions for this age group
should be 10 to 15 minutes in length. Demonstrate the use of equipment, and allow the child
to play with miniature or actual equipment. Explain procedure in simple terms and how it
affects the child.
DIF: Cognitive Level: Apply
REF: p. 575
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her
mother puts the hospital gown on her, but Katie is crying because she wants to leave on her
underpants. What is the most appropriate nursing action?
a. Allow her to wear her underpants
b. Discuss with her mother why this is important to Katie
c. Ask her mother to explain to her why she cannot wear them
d. Explain in a kind, matter-of-fact manner that this is hospital policy
ANS: A
It is appropriate for the child to leave her underpants on. This allows her some measure of
control in this procedure, foot surgery. Further discussions may make the child more upset.
Katie is too young to understand what hospital policy means.
DIF: Cognitive Level: Apply
REF: p. 578
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Using knowledge of child development, which is the best approach when preparing a toddler
for a procedure?
Avoid asking the child to make choices.
Demonstrate the procedure on a doll.
Plan for the teaching session to last about 20 minutes.
Show necessary equipment without allowing the child to handle it.
a.
b.
c.
d.
ANS: B
Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child’s
favorite doll because the toddler may think the doll is really “feeling” the procedure. In
preparing a toddler for a procedure, allow the child to participate in care and help whenever
possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica
of the equipment, and allow the child to handle it.
DIF: Cognitive Level: Apply
REF: p. 578
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. The girl tells the nurse
she wants her mother with her “like before.” What is the most appropriate nursing action?
Grant her request
Explain why this is not possible
Identify an appropriate substitute for her mother
Offer to provide support to her during the procedure
a.
b.
c.
d.
ANS: A
The parent’s preferences for assisting, observing, or waiting outside the room should be
assessed, along with the child’s preference for parental presence. The child’s choice should be
respected. If the mother and child are agreeable, then the mother is welcome to stay. An
appropriate substitute for the mother is necessary only if the mother does not wish to stay.
Support is offered to the child regardless of parental presence.
DIF: Cognitive Level: Apply
REF: p. 596
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. The emergency department nurse is cleaning multiple facial abrasions on a 9-year-old child
whose mother is present. The child is crying and screaming loudly. What is the best nursing
action?
a. Ask the child to be quieter
b. Have the child’s mother give instructions about relaxation
c. Tell the child it is okay to cry and scream
d. Remove the mother from the room
ANS: C
The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any
other emotion. The child needs to know it is all right to cry. There is no reason for the child to
be quieter and feelings need to be able to be expressed. The mother should stay in the room to
provide comfort to the child.
DIF: Cognitive Level: Apply
REF: p. 577
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. In some genetically susceptible children, anesthetic agents can trigger malignant
hyperthermia. The nurse should be alert in observing that, in addition to an increased
temperature, what is an early sign of this disorder?
a. Apnea
b. Bradycardia
c. Muscle rigidity
d. Decreased blood pressure
ANS: C
Early signs of malignant hyperthermia include tachycardia, increasing blood pressure,
tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia.
Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased blood
pressure, not decreased blood pressure, is characteristic of malignant hyperthermia.
DIF: Cognitive Level: Understand
REF: p. 583
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. The nurse is caring for an unconscious child. Skin care should include which action?
a. Avoid use of pressure reduction on bed.
b. Massage reddened bony prominences to prevent deep tissue damage.
c. Use draw sheet to move child in bed to reduce friction and shearing injuries.
d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a
protective barrier.
ANS: C
A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction
and shearing injuries. Do not drag the child from under the arms. Pressure-reduction devices
should be used to redistribute weight. Bony prominences should not be massaged if reddened.
Deep tissue damage can occur. Pressure-reduction devices should be used instead. The skin
should be cleansed with mild non-alkaline soap or soap-free cleaning agents for routine
bathing.
DIF: Cognitive Level: Apply
REF: p. 586
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. What is an appropriate intervention to encourage food and fluid intake in a hospitalized
child?
a. Force the child to eat and drink to combat caloric losses.
b. Discourage participation in non-eating activities until caloric intake is sufficient.
c. Administer large quantities of flavored fluids at frequent intervals and during
meals.
d. Give high-quality foods and snacks whenever the child expresses hunger.
ANS: D
Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods
such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and
cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the
behavior as a control mechanism. Large quantities of fluid may decrease the child’s hunger
and further inhibit food intake.
DIF: Cognitive Level: Apply
REF: p. 588
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
10. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his
“regular diet” trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream.
Which is the best nursing action?
a. Request these favorite foods for him.
b. Identify healthier food choices that he likes.
c. Explain that he needs fruits and vegetables.
d. Reward him with ice cream at the end of every meal that he eats.
ANS: A
Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate
nutrition, favorite foods should be requested for the child. These foods provide nutrition and
can be supplemented with additional fruits and vegetables. Ice cream and other desserts
should not be used as rewards or punishment.
DIF: Cognitive Level: Apply
REF: p. 608
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
11. A 3-year-old child has a fever associated with a viral illness. Her mother calls the nurse,
reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse’s
action should be based on which statement?
a. Fevers such as this are common with viral illnesses.
b. Seizures are common in children when antipyretics are ineffective.
c. Fever over 102° F indicates greater severity of illness.
d. Fever over 102° F indicates a probable bacterial infection.
ANS: A
Most fevers are of brief duration, with limited consequences, and are viral. Little evidence
supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in
temperature nor its response to antipyretics indicates the severity or etiology of infection.
DIF: Cognitive Level: Apply
REF: p. 589
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as
acetaminophen (Tylenol). What should the nurse explain about antipyretics?
a. They may cause malignant hyperthermia
b. They may cause febrile seizures
c. They are of no value in treating hyperthermia
d. They are of limited value in treating hyperthermia
ANS: C
Unlike with fever, antipyretics are of no value in hyperthermia because the set point is
already normal. Cooling measures are used instead. Malignant hyperthermia is a genetic
myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect.
Antipyretics do not cause seizures and are of no value in hyperthermia.
DIF: Cognitive Level: Apply
REF: p. 589
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. Tepid water or sponge baths are indicated for hyperthermia in children. What is the priority
nursing action?
Add isopropyl alcohol to the water.
Direct a fan on the child in the bath.
Stop the bath if the child begins to chill.
Continue the bath for 5 minutes.
a.
b.
c.
d.
ANS: C
Environmental measures such as sponge baths can be used to reduce temperature if tolerated
by the child and if they do not induce shivering. Shivering is the body’s way of maintaining
the elevated set point. Compensatory shivering increases metabolic requirements above those
already caused by the fever. Ice water and isopropyl alcohol are potentially dangerous
solutions. Fans should not be used because of the risk of the child developing
vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to
the skin surface, and the blood remains primarily in the viscera to become heated. The child
is placed in a tub of tepid water for 20 to 30 minutes.
DIF: Cognitive Level: Apply
REF: p. 589
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. The nurse approaches a group of school-age patients to administer medication to Sam Hart.
What should the nurse do to identify the correct child?
Ask the group, “Who is Sam Hart?”
Call out to the group, “Sam Hart?”
Ask each child, “What’s your name?”
Check the patient’s identification name band
a.
b.
c.
d.
ANS: D
The child must be correctly identified before the administration of any medication. Children
are not totally reliable in giving correct names on request; the identification bracelet should
always be checked. Asking children or the group for names is not an acceptable way to
identify a child. Older children may exchange places, give an erroneous name, or choose not
to respond to their name as a joke.
DIF: Cognitive Level: Apply
REF: p. 608
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
15. The nurse wore gloves during a dressing change. What should the nurse do after the gloves
are removed?
a. Wash hands thoroughly
b. Check the gloves for leaks
c. Rinse gloves in disinfectant solution
d. Apply new gloves before touching the next patient
ANS: A
When gloves are worn, the hands are washed thoroughly after removing the gloves because
both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of
after use. Hands should be thoroughly washed before new gloves are applied.
DIF: Cognitive Level: Apply
REF: p. 612
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
16. The nurse gives an injection in a patient’s room. The nurse should perform which
intervention with the needle for disposal?
a. Dispose of syringe and needle in a rigid, puncture-resistant container in the
patient’s room.
b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area
outside of the patient’s room.
c. Cap needle immediately after giving injection and dispose of in a proper container.
d. Cap needle, break from syringe, and dispose of in a proper container.
ANS: A
All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container
located near the site of use. Consequently, these containers should be installed in the patient’s
room. The uncapped needle should not be transported to an area distant from use. Needles are
disposed of uncapped and unbroken.
DIF: Cognitive Level: Apply
REF: p. 590
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
17. A mother calls the outpatient clinic requesting information on appropriate dosing for over-
the-counter medications for her 13-month-old who has symptoms of an upper respiratory
tract infection and fever. The box of acetaminophen says to give 120 mg q4h when needed.
At his 12-month visit, the nurse practitioner prescribed 150 mg. What is the nurse’s best
response?
a. “The doses are close enough; it doesn’t really matter which one is given.”
b. “It is not appropriate to use dosages based on age because children have a wide
range of weights at different ages.”
c. “From your description, medications are not necessary. They should be avoided in
children at this age.”
d. “The nurse practitioner ordered the drug based on weight, which is a more accurate
way of determining a therapeutic dose.”
ANS: D
The method most often used to determine children’s dosage is based on a specific dose per
kilogram of body weight. The mother should be given correct information. For a therapeutic
effect, the dosage should be based on weight, not age. Acetaminophen can be used to relieve
discomfort in children at this age group.
DIF: Cognitive Level: Apply
REF: p. 589
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
18. An 8-month-old infant is restrained to prevent interference with the IV infusion. How should
the nurse appropriately care for this child?
Remove the restraints once a day to allow movement.
Keep the restraints on constantly.
Keep the restraints secure so the infant remains supine.
Remove restraints whenever possible.
a.
b.
c.
d.
ANS: D
The nurse should remove the restraints whenever possible. When parents or staff are present,
the restraints can be removed and the IV site protected. Restraints must be checked and
documented every 1 to 2 hours. They should be removed for range of motion on a periodic
basis. The child should not be securely restrained in the supine position because of risks of
aspiration.
DIF: Cognitive Level: Apply
REF: p. 600
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
19. A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her
during the procedure. What information should the nurse include in her response to the child?
It is unsafe.
It is helpful to relax the child.
It is against hospital policy.
It is unnecessary because of child’s age.
a.
b.
c.
d.
ANS: B
The mother’s preference for assisting, observing, or waiting outside the room should be
assessed along with the child’s preference for parental presence. The child’s choice should be
respected. This will most likely help the child through the procedure. If the mother and child
agree, then the mother is welcome to stay. Her familiarity with the procedure should be
assessed and potential safety risks identified (mother may sit in chair). Hospital policies
should be reviewed to ensure that they incorporate family-centered care. The child should
determine whether parental support is necessary.
DIF: Cognitive Level: Understand
REF: p. 600
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When
preparing for a lumbar puncture, what is the nurse’s best action?
a. Prepare child for conscious sedation during the test.
b. Set up a tray with equipment the same size as for adults.
c. Reassure the parents that the test is simple, painless, and risk free.
d. Apply EMLA to the puncture site 15 minutes before the procedure.
ANS: A
Because of the urgency of the child’s condition, conscious sedation should be used for the
procedure. Pediatric spinal trays have smaller needles than do adult trays. Reassuring the
parents that the test is simple, painless, and risk free is incorrect information. A spinal tap
does have associated risks, and analgesia will be given for the pain. EMLA (a eutectic
mixture of anesthetics) should be applied approximately 60 minutes before the procedure.
The emergency nature of the spinal tap precludes its use.
DIF: Cognitive Level: Analyze
REF: p. 596
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
21. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant.
Which is the most appropriate way to collect small amounts of urine for these tests?
Apply a urine-collection bag to the perineal area.
Tape a small medicine cup to the inside of the diaper.
Aspirate urine from cotton balls inside the diaper with a syringe.
Aspirate urine from a superabsorbent disposable diaper with a syringe.
a.
b.
c.
d.
ANS: C
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly
from the diaper. If diapers with absorbent material are used, place a small gauze dressing or
cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For
frequent urine sampling, the collection bag would be too irritating to the child’s skin. It is not
feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the
cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
DIF: Cognitive Level: Apply
REF: p. 597
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
22. Which is an important nursing consideration when performing a bladder catheterization on a
young boy?
Clean technique, not standard precautions, is needed.
Insert 2% lidocaine lubricant into the urethra.
Lubricate catheter with water-soluble lubricant such as K-Y Jelly.
Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.
a.
b.
c.
d.
ANS: B
The anxiety, fear, and discomfort experienced during catheterization can be significantly
decreased by preparation of the child and parents, by selection of the correct catheter, and by
appropriate technique of insertion. Generous lubrication of the urethra before catheterization
and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and
discomfort associated with this procedure. Catheterization is a sterile procedure, and standard
precautions for body-substance protection should be followed. Water-soluble lubricants do
not provide appropriate local anesthesia. Catheterization should be delayed 2 to 3 minutes
only. This provides sufficient local anesthesia for the procedure.
DIF: Cognitive Level: Apply
REF: p. 597
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. The Allen test is performed as a precautionary measure before which procedure?
a. Heel stick
b. Venipuncture
c. Arterial puncture
d. Lumbar puncture
ANS: C
The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial
puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or
lumbar punctures.
DIF: Cognitive Level: Understand
REF: p. 601
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
24. The nurse must do a heel stick on an ill neonate to obtain a blood sample. What action is
recommended to facilitate blood flow?
a. Apply cool, moist compresses.
b. Apply a tourniquet to the ankle.
c. Elevate the foot for 5 minutes.
d. Wrap the foot in a warm washcloth.
ANS: D
Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10
minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood
collection more difficult. A tourniquet is used to constrict superficial veins. It will have an
insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot
available for collection.
DIF: Cognitive Level: Understand
REF: p. 601
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
25. The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the
nurse do next?
a. Keep the arm extended while applying a bandage to the site.
b. Keep the arm extended, and apply pressure to the site for a few minutes.
c. Apply a bandage to the site, and keep the arm flexed for 10 minutes.
d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several
minutes.
ANS: B
Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation.
Pressure should be applied before bandage is applied.
DIF: Cognitive Level: Apply
REF: p. 601
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. A nurse must do a venipuncture on a 6-year-old child. What is an important consideration in
providing atraumatic care?
a. Use an 18-gauge needle if possible.
b. If not successful after four attempts, have another nurse try.
c. Restrain the child only as needed to perform venipuncture safely.
d. Show the child equipment to be used before the procedure.
ANS: C
Restrain the child only as needed to perform the procedure safely; use therapeutic hugging.
Use the smallest-gauge needle that permits free flow of blood. A two-try-only policy is
desirable, in which two operators each have only two attempts. If insertion is not successful
after four punctures, alternative venous access should be considered. Keep all equipment out
of sight until used.
DIF: Cognitive Level: Apply
REF: p. 601
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. What is an appropriate method for administering oral medications that are bitter to an infant
or small child?
a. Mix in a bottle of formula or milk.
b. Mix with any food the child is going to eat.
c. Mix with a small amount (1 teaspoon) of a sweet-tasting substance such as jam or
ice cream.
d. Mix with large amounts of water to dilute medication sufficiently.
ANS: C
Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will
make the medication more palatable to the child. The medication should be mixed with only a
small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to
determine how much medication was consumed. Medication should not be mixed with
essential foods and milk. The child may associate the altered taste with the food and refuse to
eat in the future.
DIF: Cognitive Level: Apply
REF: p. 619
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
28. When liquid medication is given to a crying 10-month-old infant, which approach minimizes
the possibility of aspiration?
a. Administer the medication with a syringe (without needle) placed along the side of
the infant’s tongue.
b. Administer the medication as rapidly as possible with the infant securely
restrained.
c. Mix the medication with the infant’s regular formula or juice and administer by
bottle.
d. Keep the child upright with the nasal passages blocked for a minute after
administration.
ANS: A
Administer the medication with a syringe without needle placed along the side of the infant’s
tongue. The contents are administered slowly in small amounts, allowing the child to swallow
between deposits. Medications should be given slowly to avoid aspiration. The medication
should be mixed with only a small amount of food or liquid. If the child does not finish
drinking or eating, it is difficult to determine how much medication was consumed. Essential
foods also should not be used. Holding the child’s nasal passages will increase the risk of
aspiration.
DIF: Cognitive Level: Apply
REF: p. 619
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29. Which is the preferred site for intramuscular injections in infants?
a. Deltoid
b. Dorsogluteal
c. Rectus femoris
d. Vastus lateralis
ANS: D
The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used
for older children and adults. The rectus femoris is not a recommended site.
DIF: Cognitive Level: Understand
REF: p. 607
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
30. Guidelines for intramuscular administration of medication in school-age children include
which action?
a. Inject medication as rapidly as possible.
b. Insert needle quickly, using a dart like motion.
c. Penetrate skin immediately after cleansing site, before skin has dried.
d. Have child stand, if possible, and if child is cooperative.
ANS: B
The needle should be inserted quickly in a dart like motion at a 90-degree angle unless
contraindicated. Inject medications slowly. Allow skin preparation to dry completely before
skin is penetrated. Place child in lying or sitting position.
DIF: Cognitive Level: Apply
REF: p. 607
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
31. Several types of long-term central venous access devices are used. Which is considered an
advantage of a Hickman-Broviac catheter?
No need to keep exit site dry
Easy to use for self-administered infusions
Heparinized only monthly and after each infusion
No limitations on regular physical activity, including swimming
a.
b.
c.
d.
ANS: B
The Hickman-Broviac catheter has several benefits, including that it is easy to use for selfadministered infusions. The exit site must be kept dry to decrease risk of infection. The
Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted
because of risk of infection.
DIF: Cognitive Level: Understand
REF: p. 611
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
32. When teaching a mother how to administer eye drops, where should the nurse tell her to place
them?
In the conjunctival sac that is formed when the lower lid is pulled down
Carefully under the eye lid while it is gently pulled upward
On the sclera while the child looks to the side
Anywhere as long as drops contact the eye’s surface
a.
b.
c.
d.
ANS: A
The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is
applied to this area. The medication should not be administered directly on the eyeball.
DIF: Cognitive Level: Understand
REF: p. 617
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
33. A 2-year-old child comes to the emergency department with dehydration and hypovolemic
shock. Which best explains why an intraosseous infusion is started?
It is less painful for small children.
Rapid venous access is not possible.
Antibiotics must be started immediately.
Long-term central venous access is not possible.
a.
b.
c.
d.
ANS: B
In situations in which rapid establishment of systemic access is vital and venous access is
hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous
infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local
anesthetics and systemic analgesics are given. Antibiotics could be given when vascular
access is obtained. Long-term central venous access is time-consuming, and intraosseous
infusion is used in an emergency situation.
DIF: Cognitive Level: Analyze
REF: p. 612
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
34. What should the nurse do when caring for a child with an intravenous infusion?
a. Use a macrodropper to facilitate reaching the prescribed flow rate.
b. Avoid restraining the child to prevent undue emotional stress.
c. Change the insertion site every 24 hours.
d. Observe the insertion site frequently for signs of infiltration.
ANS: D
The nursing responsibility for IV therapy is to calculate the amount to be infused in a given
length of time; set the infusion rate; and monitor the apparatus frequently (at least every 1 to
2 hours) to make certain that the desired rate is maintained, the integrity of the system
remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and
the infusion does not stop. A minidropper (60 drops/ml) is the recommended IV tubing in
pediatrics. The IV site should be protected. This may require soft restraints on the child.
Insertion sites do not need to be changed every 24 hours unless a problem is found with the
site. This exposes the child to significant trauma.
DIF: Cognitive Level: Apply
REF: p. 615
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
35. What is a nursing consideration related to the administration of oxygen in an infant?
a. Humidify oxygen if the infant can tolerate it.
b. Assess the infant to determine how much oxygen should be given.
c. Ensure uninterrupted delivery of the appropriate oxygen concentration.
d. Direct oxygen flow so that it blows directly into the infant’s face in a hood.
ANS: C
Oxygen is a prescribed medication. It is the nurse’s responsibility to ensure that the ordered
concentration is delivered and the effects of therapy are monitored. Oxygen is drying to the
tissues. Oxygen should always be humidified when delivered to a patient. A child receiving
oxygen therapy should have the oxygen saturation monitored at least as frequently as vital
signs. Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage
as indicated. Humidified oxygen should not be blown directly into an infant’s face.
DIF: Cognitive Level: Understand
REF: p. 325
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
36. It is important to make certain that sensory connectors and oximeters are compatible. What
can incompatible wiring cause?
a. Hyperthermia
b. Electrocution
c. Pressure necrosis
d. Burns under sensors
ANS: D
It is important to make certain that sensor connectors and oximeters are compatible. Wiring
that is incompatible can generate considerable heat at the tip of the sensor, causing secondand third-degree burns under the sensor. Incompatibility would cause a local irritation or
burn. A low voltage is used, which should not present risk of electrocution. Pressure necrosis
can occur from the sensor being attached too tightly, but this is not a problem of
incompatibility.
DIF: Cognitive Level: Understand
REF: p. 626
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37. The nurse is teaching a mother how to perform chest physical therapy and postural drainage
on her 3-year-old child, who has cystic fibrosis. How should the nurse instruct the mother?
a. Cover the skin with a shirt or gown before percussing.
b. Strike the chest wall with a flat-hand position.
c. Percuss over the entire trunk anteriorly and posteriorly.
d. Percuss before positioning for postural drainage.
ANS: A
For postural drainage and percussion, the child should be dressed in a light shirt to protect the
skin and placed in the appropriate postural drainage positions. The chest wall is struck with a
cupped-hand, not a flat-hand position. The procedure should be done over the rib cage only.
Positioning precedes the percussion.
DIF: Cognitive Level: Apply
REF: p. 627
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
38. The nurse must suction a child with a tracheostomy. What is the appropriate technique?
a. Encourage the child to cough to raise the secretions before suctioning.
b. Select a catheter with diameter three-fourths as large as the diameter of the
tracheostomy tube.
c. Ensure each pass of the suction catheter should take no longer than 5 seconds.
d. Allow the child to rest after every five times the suction catheter is passed.
ANS: C
Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be
occluded for too long. If the child is able to cough up secretions, suctioning may not be
indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it
is too large, it might block the child’s airway. The child is allowed to rest for 30 to 60 seconds
after each aspiration to allow oxygen tension to return to normal. Then the process is repeated
until the trachea is clear.
DIF: Cognitive Level: Apply
REF: p. 628
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
39. How should the nurse administer a gavage feeding to a school-age child?
a. Lubricate the tip of the feeding tube with Vaseline to facilitate passage.
b. Check the placement of the tube by inserting 20 ml of sterile water.
c. Administer feedings over 5 to 10 minutes.
d. Position the patient on the right side after administering feeding.
ANS: D
Position the child with the head elevated about 30 degrees and on the right side or abdomen
for at least 1 hour. This is in the same manner as after any infant feeding to minimize the
possibility of regurgitation and aspiration. Insert a tube that has been lubricated with sterile
water or water-soluble lubricant. With a syringe, inject a small amount of air into the tube,
while simultaneously listening with a stethoscope over the stomach area. Feedings should be
administered via gravity flow and take from 15 to 30 minutes to complete.
DIF: Cognitive Level: Apply
REF: p. 594
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours,
the nurse observes the solution and notes that 200 ml/8 hr is being infused rather than the
ordered amount of 300 ml/8 hr. The nurse should adjust the rate so that how much will infuse
during the next 8 hours?
a. 200 ml
b. 300 ml
c. 350 ml
d. 400 ml
ANS: B
The TPN infusion rate should not be increased or decreased without the practitioner being
informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes
from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.
DIF: Cognitive Level: Apply
REF: p. 610
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
41. In preparing to give “enemas until clear” to a young child, the nurse should select which
solution?
Tap water
Normal saline
Oil retention
Fleet solution
a.
b.
c.
d.
ANS: B
Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is
not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid
overload. Oil-retention enemas will not achieve the “until clear” result. Fleet enemas are not
advised for children because of the harsh action of the ingredients. The osmotic effects of the
Fleet enema can result in diarrhea, which can lead to metabolic acidosis.
DIF: Cognitive Level: Apply
REF: p. 624
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
42. The nurse is doing a pre-hospitalization orientation for a 7-year-old child who is scheduled
for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to
talk because of an endotracheal tube but that she will be able to talk when it is removed. This
explanation is:
a. unnecessary.
b. the surgeon’s responsibility.
c. too stressful for a young child.
d. an appropriate part of the child’s preparation.
ANS: D
Explanation is a necessary part of preoperative preparation. If the child wakes and is not
prepared for the inability to speak, she will be even more anxious. This is a necessary
component for preparation for surgery that will help reduce the anxiety associated with
surgery. It is a joint responsibility of nursing, medical staff, and child life personnel.
DIF: Cognitive Level: Analyze
REF: p. 584
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The advantages of the ventrogluteal muscle as an injection site in young children include
which considerations? (Select all that apply.)
a. Less painful than vastus lateralis
b. Free of important nerves and vascular structures
c. Cannot be used when child reaches a weight of 20 pounds
d. Increased subcutaneous fat, which increases drug absorption
e. Easily identified by major landmarks
ANS: A, B, E
The advantages of the ventrogluteal are being less painful, free of important nerves and
vascular lateralis, and easily identified by major landmarks. The major disadvantage is lack of
familiarity by health professionals and controversy over whether the site can be used before
weight bearing. The use of the ventrogluteal has not been clarified. It has been used in
infants, but clinical guidelines address the need for the child to be walking, thus generally
being over 20 pounds. The site has less subcutaneous tissue, which facilitates intramuscular
(rather than subcutaneous) deposition of the drug.
DIF: Cognitive Level: Understand
REF: p. 605
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
2. A nurse is caring for a child in droplet precautions. Which instructions should the nurse give
to the unlicensed assistive personnel caring for this child? (Select all that apply.)
a. Wear gloves when entering the room.
b. Wear an isolation gown when entering the room.
c. Place the child in a special air handling and ventilation room.
d. A mask should be worn only when holding the child.
e. Wash your hands upon exiting the room.
ANS: A, B, E
Droplet transmission involves contact of the conjunctivae or the mucous membranes of the
nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing
microorganisms generated from a person who has a clinical disease or who is a carrier of the
microorganism. Droplets are generated from the source person primarily during coughing,
sneezing, or talking and during procedures such as suctioning and bronchoscopy. Gloves,
gowns, and a mask should be worn when entering the room. Hand washing when exiting the
room should be done with any patient. Because droplets do not remain suspended in the air,
special air handling and ventilation are not required to prevent droplet transmission.
DIF: Cognitive Level: Apply
REF: p. 591
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
COMPLETION
1. A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin).
The dosage is 0.07 mg/kg/day, and the child’s weight is 7.2 kg. The physician prescribes the
digoxin to be given once a day by mouth. Each dose will be _____ milligrams. (Record your
answer below using one decimal place.)
ANS:
0.5
Calculate the dosage by weight: 0.07 mg/day ´ 7.2 kg = 0.5 mg/day.
DIF: Cognitive Level: Analyze
REF: p. 585
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
2. A physician’s prescription reads, “ampicillin sodium 125 mg IV every 6 hours.” The
medication label reads, “1 g = 7.4 ml.” A nurse prepares to draw up _____ milliliters to
administer one dose. (Round your answer to two decimal places.)
ANS:
0.93
Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by
1000 or move the decimal point three places to the right.
1 g = 1000 mg
Formula:
Desired ´ Volume = 125 mg/1000 mg ´ 7.4 ml = 0.925 round to 0.93 ml.
Available
DIF: Cognitive Level: Analyze
REF: p. 619
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
SHORT ANSWER
1. A 6-month-old infant is admitted to the pediatric unit with respiratory syncytial virus (RSV).
The nurse places the infant on strict intake and output. The infant is in a size #2 diaper and
the dry weight is 24 g. At the end of the shift, the infant has had two diapers with urine. One
diaper weighed 56 g and one weighed 65 g. What is the total milliliter output for the shift?
(Record your answer as a whole number below.)
ANS:
73
1 g of wet diaper weight = 1 ml of urine.
The dry weight of the diaper is 24 g.
56 g – 24 g = 32 ml.
65 g – 24 g = 41 ml.
32 ml + 24 ml = 73 ml total output for the shift.
DIF: Cognitive Level: Apply
REF: p. 602
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
OTHER
1. The nurse is preparing to insert a nasogastric tube into a 4-year-old child for intermittent
suctioning after abdominal surgery. Place in correct sequence the steps for inserting a
nasogastric tube. Provide the answer using lowercase letters separated by commas (e.g., a, b,
c, d, e, f).
a. Lubricate the nasogastric tube with water-soluble lubricant.
b. Tape the nasogastric tube securely to the child’s face.
c. Check the placement of the tube by aspirating stomach contents.
d. Place the child in the supine position with head slightly hyperflexed.
e. Insert the nasogastric tube through the nares.
f. Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid
process and the umbilicus.
ANS:
d, f, a, e, c, b
DIF: Cognitive Level: Remember
REF: p. 621
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 21: The Child with Respiratory Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is teaching nursing students about normal physiologic changes in the respiratory
system of toddlers. Which best describes why toddlers have fewer respiratory tract infections
as they grow older?
a. The amount of lymphoid tissue decreases.
b. Repeated exposure to organisms causes increased immunity.
c. Viral organisms are less prevalent in the population.
d. Secondary infections rarely occur after viral illnesses.
ANS: B
Children have increased immunity after exposure to a virus. The amount of lymphoid tissue
increases as children grow older. Viral organisms are not less prevalent, but older children
have the ability to resist invading organisms. Secondary infections after viral illnesses include
Mycoplasma pneumoniae and group A b-hemolytic streptococcal infections.
DIF: Cognitive Level: Understand
REF: p. 636
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. A nurse is charting that a hospitalized child has labored breathing. Which describes labored
breathing?
Dyspnea
Tachypnea
Hypopnea
Orthopnea
a.
b.
c.
d.
ANS: A
Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is too
shallow. Orthopnea is difficulty breathing except in an upright position.
DIF: Cognitive Level: Remember
REF: p. 639
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which explains why cool-mist vaporizers rather than steam vaporizers are recommended in
home treatment of childhood respiratory tract infections?
They are safer.
They are less expensive.
Respiratory secretions are dried.
A more comfortable environment is produced.
a.
b.
c.
d.
ANS: A
Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any
advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam
loosens secretions, not dries them. Both may promote a more comfortable environment, but
cool-mist vaporizers present decreased risk for burns and growth of organisms.
DIF: Cognitive Level: Understand
REF: p. 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. Decongestant nose drops are recommended for a 10-month-old infant with an upper
respiratory tract infection. Instructions for nose drops should include which action?
Avoid using for more than 3 days.
Keep drops to use again for nasal congestion.
Administer drops until nasal congestion subsides.
Administer drops after feedings and at bedtime.
a.
b.
c.
d.
ANS: A
Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for
more than 3 days to avoid rebound congestion. Drops should be discarded after one illness
because they may become contaminated with bacteria. Vasoconstrictive nose drops can have
a rebound effect after 3 days of use. Drops administered before feedings are more helpful.
DIF: Cognitive Level: Apply
REF: p. 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
5. Which is an appropriate nursing intervention when caring for an infant with an upper
respiratory tract infection and elevated temperature?
Give tepid water baths to reduce fever.
Encourage food intake to maintain caloric needs.
Have child wear heavy clothing to prevent chilling.
Give small amounts of favorite fluids frequently to prevent dehydration.
a.
b.
c.
d.
ANS: D
Preventing dehydration by small frequent feedings is an important intervention in the febrile
child. Tepid water baths may induce shivering, which raises temperature. Food should not be
forced; it may result in the child vomiting. The febrile child should be dressed in light, loose
clothing.
DIF: Cognitive Level: Apply
REF: p. 640
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The parent of an infant with nasopharyngitis should be instructed to notify the health
professional if the infant displays which clinical manifestation?
a. Fussiness
b. Coughing
c. A fever over 99° F
d. Signs of an earache
ANS: D
If an infant with nasopharyngitis shows signs of an earache, it may mean a secondary
bacterial infection is present and the infant should be referred to a practitioner for evaluation.
Irritability is common in an infant with a viral illness. Cough can be a sign of
nasopharyngitis. Fever is common in viral illnesses.
DIF: Cognitive Level: Apply
REF: p. 640
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. When is it generally recommended that a child with acute streptococcal pharyngitis may
return to school?
When sore throat is better.
If no complications develop.
After taking antibiotics for 24 hours.
After taking antibiotics for 3 days.
a.
b.
c.
d.
ANS: C
After children have taken antibiotics for 24 hours, they are no longer contagious to other
children. Sore throat may persist longer than 24 hours after beginning antibiotic therapy, but
the child is no longer considered contagious. Complications may take days to weeks to
develop.
DIF: Cognitive Level: Understand
REF: p. 641
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
8. A child is diagnosed with influenza. Management includes which recommendation?
a. Clear liquid diet for hydration
b. Aspirin to control fever
c. Oseltamivie (Tamiflu)
d. Antibiotics to prevent bacterial infection
ANS: C
Oseltamivie (Tamiflu) may reduce symptoms related to influenza A if administered within 24
to 48 hours of onset. A clear liquid diet is not necessary for influenza, but maintaining
hydration is important. Aspirin is not recommended in children because of increased risk of
Reye syndrome. Acetaminophen or ibuprofen is a better choice. Preventive antibiotics are not
indicated for influenza unless there is evidence of a secondary bacterial infection.
DIF: Cognitive Level: Apply
REF: p. 644
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
9. How is chronic otitis media with effusion (OME) differentiated from acute otitis media
(AOM)?
A fever as high as 40° C (104° F)
Severe pain in the ear
Nausea and vomiting
A feeling of fullness in the ear
a.
b.
c.
d.
ANS: D
OME is characterized by feeling of fullness in the ear or other nonspecific complaints. Fever
is a sign of AOM. OME does not cause severe pain. This may be a sign of AOM. Nausea and
vomiting are associated with otitis media.
DIF: Cognitive Level: Understand
REF: p. 645
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. Parents have understood teaching about prevention of childhood otitis media if they make
which statement?
a. “We will only prop the bottle during the daytime feedings.”
b. “Breastfeeding will be discontinued after 4 months of age.”
c. “We will place the child flat right after feedings.”
d. “We will be sure to keep immunizations up to date.”
ANS: D
Parents have understood the teaching about preventing childhood otitis media if they respond
they will keep childhood immunizations up to date. The child should be maintained upright
during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at
least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the
child is in the supine position.
DIF: Cognitive Level: Analyze
REF: p. 645
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
11. An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole
(Bactrim) is prescribed. Which statement made by the parent indicates a correct
understanding of the instructions?
a. “I should administer all the prescribed medication.”
b. “I should continue medication until the symptoms subside.”
c. “I will immediately stop giving medication if I notice a change in hearing.”
d. “I will stop giving medication if fever is still present in 24 hours.”
ANS: A
Antibiotics should be given for their full course to prevent recurrence of infection with
resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a
complication of AOM. Antibiotics should continue to be given. Medication may take 24 to 48
hours to make symptoms subside. It should be continued.
DIF: Cognitive Level: Apply
REF: p. 645
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
12. An infant’s parents ask the nurse about preventing OM. Which should be recommended?
a. Avoid tobacco smoke.
b. Use nasal decongestant.
c. Avoid children with OM.
d. Bottle-feed or breastfeed in a supine position.
ANS: A
Eliminating tobacco smoke from the child’s environment is essential for preventing OM and
other common childhood illnesses. Nasal decongestants are not useful in preventing OM.
Children with uncomplicated OM are not contagious unless they show other upper respiratory
tract infection (URI) symptoms. Children should be fed in an upright position to prevent OM.
DIF: Cognitive Level: Apply
REF: p. 645
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. The nurse is assessing a child with acute epiglottitis. Examining the child’s throat by using a
tongue depressor might precipitate which symptom or condition?
Inspiratory stridor
Complete obstruction
Sore throat
Respiratory tract infection
a.
b.
c.
d.
ANS: B
If a child has acute epiglottitis, examination of the throat may cause complete obstruction and
should be performed only when immediate intubation can take place. Stridor is aggravated
when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of
epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.
DIF: Cognitive Level: Understand
REF: p. 648
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. Which type of croup is always considered a medical emergency?
a. Laryngitis
b. Epiglottitis
c. Spasmodic croup
d. Laryngotracheobronchitis (LTB)
ANS: B
Epiglottitis is always a medical emergency needing antibiotics and airway support for
treatment. Laryngitis is a common viral illness in older children and adolescents, with
hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress
to a medical emergency in some children.
DIF: Cognitive Level: Understand
REF: p. 648
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to
stay at the bedside as much as possible. The nurse’s rationale for this action is described
primarily in which statement?
a. Mothers of hospitalized toddlers often experience guilt.
b. The mother’s presence will reduce anxiety and ease the child’s respiratory efforts.
c. Separation from the mother is a major developmental threat at this age.
d. The mother can provide constant observations of the child’s respiratory efforts.
ANS: B
The family’s presence will decrease the child’s distress. It is true that mothers of hospitalized
toddlers often experience guilt but this is not the best answer. The main reason to keep
parents at the child’s bedside is to ease anxiety and therefore respiratory effort. The child
should have constant monitoring by cardiorespiratory monitor and noninvasive oxygen
saturation monitoring, but the parent should not play this role in the hospital.
DIF: Cognitive Level: Apply
REF: p. 648
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Adaptation
16. A school-age child had an upper respiratory tract infection for several days and then began
having a persistent dry, hacking cough that was worse at night. The cough has become
productive in the past 24 hours. This is most suggestive of which diagnosis?
a. Bronchitis
b. Bronchiolitis
c. Viral-induced asthma
d. Acute spasmodic laryngitis
ANS: A
Bronchitis is characterized by these symptoms and occurs in children older than 6 years.
Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the
airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children
between 3 months and 3 years of age.
DIF: Cognitive Level: Understand
REF: p. 650
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. Which frequency is recommended for childhood skin testing for tuberculosis (TB) using the
Mantoux test?
Every year for all children older than 2 years
Every year for all children older than 10 years
Every 2 years for all children starting at age 1 year
Periodically for children who reside in high-prevalence regions
a.
b.
c.
d.
ANS: D
Children who reside in high-prevalence regions for TB should be tested every 2 to 3 years.
Annual testing is not necessary. Testing is not necessary unless exposure is likely or an
underlying medical risk factor is present.
DIF: Cognitive Level: Remember
REF: p. 656
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. Which consideration is the most important in managing tuberculosis (TB) in children?
a. Skin testing annually
b. Pharmacotherapy
c. Adequate nutrition
d. Adequate hydration
ANS: B
Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and
two or three times a week for the remaining 4 months. Pharmacotherapy is the most
important intervention for TB.
DIF: Cognitive Level: Apply
REF: p. 656
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. The mother of a toddler yells to the nurse, “Help! He is choking to death on his food.” The
nurse determines that lifesaving measures are necessary based on which symptom?
Gagging
Coughing
Pulse over 100 beats/min
Inability to speak
a.
b.
c.
d.
ANS: D
The inability to speak is indicative of a foreign-body airway obstruction of the larynx.
Abdominal thrusts are needed for treatment of the choking child. Gagging indicates irritation
at the back of the throat, not obstruction. Coughing does not indicate a complete airway
obstruction. Tachycardia may be present for many reasons.
DIF: Cognitive Level: Apply
REF: p. 659
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated
with sepsis. What is the priority nursing intervention?
a. Forcing fluids
b. Monitoring pulse oximetry
c. Instituting seizure precautions
d. Encouraging a high-protein diet
ANS: B
Monitoring cardiopulmonary status is an important evaluation tool in the care of the child
with ARDS. Maintenance of vascular volume and hydration is important and should be done
parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a
high-protein diet is not helpful.
DIF: Cognitive Level: Apply
REF: p. 661
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
21. The nurse is caring for a child with carbon monoxide poisoning associated with smoke
inhalation. Which is essential in this child’s care?
a. Monitor pulse oximetry.
b. Monitor arterial blood gases.
c. Administer oxygen if respiratory distress develops.
d. Administer oxygen if child’s lips become bright, cherry red.
ANS: B
Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry
is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be
normal. The child should receive 100% oxygen as quickly as possible, not only if respiratory
distress or other symptoms develop.
DIF: Cognitive Level: Apply
REF: p. 662
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A nurse is admitting an infant with asthma. What usually triggers asthma in infants?
a. Medications
b. A viral infection
c. Exposure to cold air
d. Allergy to dust or dust mites
ANS: B
Viral illnesses cause inflammation that causes increased airway reactivity in asthma.
Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics
may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate
already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with
asthma have no evidence of allergic disease.
DIF: Cognitive Level: Understand
REF: p. 663
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. A nurse is conducting an in-service on asthma. Which statement is the most descriptive of
bronchial asthma?
There is heightened airway reactivity.
There is decreased resistance in the airway.
The single cause of asthma is an allergic hypersensitivity.
It is inherited.
a.
b.
c.
d.
ANS: A
In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes
constriction, producing impaired respiratory function. In bronchial asthma, there is increased
resistance in the airway. There are multiple causes of asthma, including allergens, irritants,
exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy
or development of an immunoglobulin E (IgE)–mediated response is inherited but is not the
only cause of asthma.
DIF: Cognitive Level: Understand
REF: p. 664
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
24. A child is admitted to the hospital with asthma. Which assessment findings support this
diagnosis?
Nonproductive cough, wheezing
Fever, general malaise
Productive cough, rales
Stridor, substernal retractions
a.
b.
c.
d.
ANS: A
Asthma presents with a nonproductive cough and wheezing. Pneumonia appears with an
acute onset, fever, and general malaise. A productive cough and rales would be indicative of
pneumonia. Stridor and substernal retractions are indicative of croup.
DIF: Cognitive Level: Understand
REF: p. 664
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. It is now recommended that children with asthma who are taking long-term inhaled steroids
should be assessed frequently because which disease or assessment findings may develop?
Cough
Osteoporosis
Slowed growth
Cushing syndrome
a.
b.
c.
d.
ANS: C
The growth of children on long-term inhaled steroids should be assessed frequently to assess
for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence
exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term
systemic steroids.
DIF: Cognitive Level: Understand
REF: p. 664
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
26. b-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma
attack. Which describes their action?
Liquefy secretions
Dilate the bronchioles
Reduce inflammation of the lungs
Reduce infection
a.
b.
c.
d.
ANS: B
b-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute
exacerbations. These medications do not liquefy secretions or reduce infection.
Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.
DIF: Cognitive Level: Understand
REF: p. 664
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
27. Parents of two school-age children with asthma ask the nurse, “What sports can our children
participate in?” The nurse should recommend which sport?
Soccer
Running
Swimming
Basketball
a.
b.
c.
d.
ANS: C
Swimming is well tolerated in children with asthma because they are breathing air fully
saturated with moisture and because of the type of breathing required in swimming. Exerciseinduced bronchospasm is more common in sports that involve endurance, such as soccer.
Prophylaxis with medications may be necessary.
DIF: Cognitive Level: Apply
REF: p. 664
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
28. Which drug is usually given first in the emergency treatment of an acute, severe asthma
episode in a young child?
a. Ephedrine
b. Theophylline
c. Aminophylline
d. Short-acting b2 agonists
ANS: D
Short-acting b2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is
not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma
exacerbations. Aminophylline is not helpful for acute asthma exacerbation.
DIF: Cognitive Level: Apply
REF: p. 666
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29. Parents of a child with cystic fibrosis ask the nurse about genetic implications of the disorder.
Which statement, made by the nurse, expresses accurately the genetic implications?
If it is present in a child, both parents are carriers of this defective gene.
It is inherited as an autosomal dominant trait.
It is a genetic defect found primarily in non-Caucasian population groups.
There is a 50% chance that siblings of an affected child also will be affected.
a.
b.
c.
d.
ANS: A
CF is an autosomal recessive gene inherited from both parents and is inherited as an
autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian
populations. An autosomal recessive inheritance pattern means that there is a 25% chance a
sibling will be infected but a 50% chance a sibling will be a carrier.
DIF: Cognitive Level: Understand
REF: p. 673
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30. A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF).
Which is/are the earliest recognizable clinical manifestation(s) of CF?
Meconium ileus
History of poor intestinal absorption
Foul-smelling, frothy, greasy stools
Recurrent pneumonia and lung infections
a.
b.
c.
d.
ANS: A
The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of
children with CF. Clinical manifestations include abdominal distention, vomiting, failure to
pass stools, and rapid development of dehydration. History of malabsorption is a later sign
that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF.
Recurrent respiratory tract infections are a later sign of CF.
DIF: Cognitive Level: Understand
REF: p. 674
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
31. A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests
should the nurse expect?
Sweat chloride test, stool for fat, chest radiograph films
Stool test for fat, gastric contents for hydrochloride, chest radiograph films
Sweat chloride test, bronchoscopy, duodenal fluid analysis
Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa
a.
b.
c.
d.
ANS: A
A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a
gastrointestinal (GI) manifestation of CF, and a chest radiograph showing patchy atelectasis
and obstructive emphysema indicates CF. Gastric contents contain hydrochloride normally; it
is not diagnostic. Bronchoscopy and duodenal fluid are not diagnostic. Stool test for trypsin
and intestinal biopsy are not helpful in diagnosing CF.
DIF: Cognitive Level: Understand
REF: p. 675
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
32. Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this
diagnosis?
a. Bronchoscopy
b. Serum calcium
c. Urine creatinine
d. Sweat chloride test
ANS: D
A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy,
although helpful for identifying bacterial infection in children with CF, is not diagnostic.
Serum calcium is normal in children with CF. Urine creatinine is not diagnostic of CF.
DIF: Cognitive Level: Understand
REF: p. 675
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
33. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When
should this medication be administered?
Before chest physiotherapy (CPT)
After CPT
Before receiving 100% oxygen
After receiving 100% oxygen
a.
b.
c.
d.
ANS: A
Bronchodilators should be given before CPT to open bronchi and make expectoration easier.
Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen
administration is necessary only in acute episodes with caution because of chronic carbon
dioxide retention.
DIF: Cognitive Level: Apply
REF: p. 638
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
34. A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease
(DNase). Which is an adverse effect of this medication?
a. Mucus thickens
b. Voice alters
c. Tachycardia
d. Jitteriness
ANS: B
One of the only adverse effects of DNase is voice alterations and laryngitis. DNase decreases
viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12
years. b2 Agonists can cause tachycardia and jitteriness.
DIF: Cognitive Level: Apply
REF: p. 673
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
35. Pancreatic enzymes are administered to the child with cystic fibrosis (CF). What nursing
considerations should be included?
Do not administer pancreatic enzymes if the child is receiving antibiotics.
Decrease dose of pancreatic enzymes if the child is having frequent, bulky stools.
Administer pancreatic enzymes between meals if at all possible.
Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of
food taken at the beginning of a meal.
a.
b.
c.
d.
ANS: D
Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal
or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The
dosage of enzymes should be increased if the child is having frequent, bulky stools. Enzymes
should be given just before meals and snacks.
DIF: Cognitive Level: Apply
REF: p. 673
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
36. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse
keep in mind?
a. Diet should be high in carbohydrates and protein
b. Diet should be high in easily digested carbohydrates and fats
c. Most fruits and vegetables are not well tolerated.
d. Fats and proteins must be greatly curtailed.
ANS: A
Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired
intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not
necessary. A well-balanced diet containing fruits and vegetables is important. Fats and
proteins are a necessary part of a well-balanced diet.
DIF: Cognitive Level: Understand
REF: p. 673
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37. Cardiopulmonary resuscitation (CPR) is begun on a toddler. Which pulse is usually palpated
because it is the most central and accessible?
a. Radial
b. Carotid
c. Femoral
d. Brachial
ANS: B
In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse.
The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants
younger than 1 year.
DIF: Cognitive Level: Understand
REF: p. 681
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
38. Which drug is considered the most useful in treating childhood cardiac arrest?
a. Bretylium tosylate (Bretylium)
b. Lidocaine hydrochloride (Lidocaine)
c. Epinephrine hydrochloride (Adrenaline)
d. Naloxone (Narcan)
ANS: C
Epinephrine works on alpha and beta receptors in the heart and is the most useful drug in
childhood cardiac arrest. Bretylium is no longer used in pediatric cardiac arrest management.
Lidocaine is used for ventricular arrhythmias only. Naloxone is useful only to reverse effects
of opioids.
DIF: Cognitive Level: Understand
REF: p. 681
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
39. Effective lone-rescuer CPR on a 5-year-old child should include
a. two breaths to every 30 chest compressions.
b. two breaths to every 15 chest compressions.
c. reassessment of the child after 50 cycles of compression and ventilation.
d. reassessment of the child every 10 minutes that CPR continues.
ANS: A
Lone-rescuer CPR is two breaths to 30 compressions for all ages until signs of recovery
occur. Reassessment of the child should take place after 20 cycles or 1 minute.
DIF: Cognitive Level: Apply
REF: p. 681
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
40. The Heimlich maneuver is recommended for airway obstruction in children older than _____
year(s).
1
4
8
12
a.
b.
c.
d.
ANS: A
The Heimlich maneuver is recommended for airway obstruction in children older than 1 year.
In children younger than 1 year, back blows and chest thrusts are administered. The Heimlich
maneuver can be used in children older than 1 year.
DIF: Cognitive Level: Understand
REF: p. 685
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
41. A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates
the child is still in respiratory acidosis?
a. pH 7.50, CO2 48
b. pH 7.30, CO2 30
c. pH 7.32, CO2 50
d. pH 7.48, CO2 33
ANS: C
Respiratory failure is a process that involves pulmonary dysfunction generally resulting in
impaired alveolar gas exchange, which can lead to hypoxemia or hypercapnia. Acidosis
indicates the pH is less than 7.35 and the CO2 is greater than 45. If the pH is less than 7.35 but
the CO2 is low, it is metabolic acidosis. Alkalosis is when the pH is greater than 7.45. If the
pH is high and the CO2 is high, it is metabolic alkalosis. When the pH is high and the CO2 is
low, it is respiratory alkalosis.
DIF: Cognitive Level: Analyze
REF: p. 662
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
42. A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent
has understood the teaching if which statement is made?
“I will record the average of the readings.”
“I should be sitting comfortably when I perform the readings.”
“I will record the readings at the same time every day.”
“I will repeat the routine two times.”
a.
b.
c.
d.
ANS: C
Instructions for use of a peak flowmeter include standing up straight before performing the
reading, recording the highest of the three readings (not the average), measuring the peak
expiratory flow rate (PEFR) close to the same time each day, and repeating the entire routine
three times, waiting 30 seconds between each routine.
DIF: Cognitive Level: Apply
REF: p. 666
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
43. A school-age child has been admitted with an acute asthma episode. The child is receiving
oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child’s
pulse oximetry status?
a. Continuous
b. Every 30 minutes
c. Every hour
d. Every 2 hours
ANS: A
The child on supplemental oxygen requires intermittent or continuous oxygenation
monitoring, depending on severity of respiratory compromise and initial oxygenation status.
The child in status asthmaticus should be placed on continuous cardiorespiratory (including
blood pressure) and pulse oximetry monitoring.
DIF: Cognitive Level: Apply
REF: p. 664
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
44. A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV
positive. Which induration size indicates a positive result for this child 48 to 72 hours after
the test?
a. ³5 mm
b. ³10 mm
c. ³15 mm
d. ³20 mm
ANS: A
Clinical evidence of a positive TST in children receiving immunosuppressive therapy,
including immunosuppressive doses of steroids or who have immunosuppressive conditions,
including HIV infection is an induration of ³5 mm. Children younger than 4 years of age: (a)
with other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus,
chronic renal failure, or malnutrition; (b) born or whose parents were born in high-prevalence
(TB) regions of the world; (c) frequently exposed to adults who are HIV infected, homeless,
users of illicit drugs, residents of nursing homes, incarcerated or institutionalized, or migrant
farm workers; and (d) who travel to high-prevalence (TB) regions of the world are positive
when the induration is ³10 mm. Children 4 years of age or older without any risk factors are
positive when the induration is ³20 mm.
DIF: Cognitive Level: Understand
REF: p. 657
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
45. Home care is being considered for a young child who is ventilator-dependent. Which factor is
most important in deciding whether home care is appropriate?
Level of parents’ education
Presence of two parents in the home
Preparation and training of family
Family’s ability to assume all health care costs
a.
b.
c.
d.
ANS: C
One of the essential elements is the family’s training and preparation. The family must be
able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed
that nursing care will be available on a continual basis, and the family will have to care for
the child. The amount of formal education reached by the parents is not the important issue.
The determinant is the family’s ability to care adequately for the child in the home. At least
two family members should learn and demonstrate all aspects of the child’s care in the
hospital, but it does not have to be two parents. Few families can assume all health care costs.
Creative financial planning, including negotiating arrangements with the insurance company
and/or public programs, may be required.
DIF: Cognitive Level: Analyze
REF: p. 645
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. An infant has developed staphylococcal pneumonia. Nursing care of the child with
pneumonia includes which interventions? (Select all that apply.)
a. Cluster care to conserve energy
b. Round-the-clock administration of antitussive agents
c. Strict intake and output to avoid congestive heart failure
d. Administration of antibiotics
ANS: A, D
Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased
pulmonary reserve, and the clustering of care is essential. Antitussive agents are used
sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential
to kept secretions as liquefied as possible.
DIF: Cognitive Level: Apply
REF: p. 660
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV)
bronchiolitis. Which intervention should be included in the child’s care? (Select all that
apply.)
a. Place in a mist tent.
b. Administer antibiotics.
c. Administer cough syrup.
d. Encourage the child to drink 8 ounces of formula every 4 hours.
e. Cluster care to encourage adequate rest.
f. Place on noninvasive oxygen monitoring.
ANS: D, E, F
Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent
shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen
monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses
with viral causes. Cough syrup suppresses clearing of respiratory secretions and is not
indicated for young children.
DIF: Cognitive Level: Apply
REF: p. 653
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours.
Which action should the nurse include in the child’s postoperative care plan? (Select all that
apply.)
a. Notify the surgeon if the child swallows frequently.
b. Apply a heat collar to the child for pain relief.
c. Place the child on the abdomen until fully wake.
d. Allow the child to have diluted juice after the procedure.
e. Encourage the child to cough frequently.
ANS: A, C, D
Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should
be placed on the abdomen or the side to facilitate drainage. The child can drink diluted juice,
cool water, or popsicles after the procedure. An ice collar should be used after surgery.
Frequent coughing and nose blowing should be avoided.
DIF: Cognitive Level: Apply
REF: p. 643
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A
chest tube has been inserted to promote continuous closed chest drainage. Which
interventions should the nurse implement when caring for this child? (Select all that apply.)
a. Positioning child on the right side
b. Assessing the chest tube and drainage device for correct settings
c. Administering prescribed doses of analgesia
d. Clamping the chest tube when child ambulates
e. Monitoring for need of supplemental oxygen
ANS: B, C, E
Nursing care of the child with a chest tube requires close attention to respiratory status; the
chest tube and drainage device used are monitored for proper function (i.e., drainage is not
impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube
insertion site is intact, water seal is maintained, and chest tube remains in place). Movement
in bed and ambulation with a chest tube are encouraged according to the child’s respiratory
status, but children require frequent doses of analgesia. Supplemental oxygen may be
required in the acute phase of the illness and may be administered by nasal cannula, face
mask, flow-by, or face tent. The child should be positioned on the left side, not the right.
Lying on the affected side if the pneumonia is unilateral (“good lung up”) splints the chest on
that side and reduces the pleural rubbing that often causes discomfort. The chest tube should
never be clamped; this can cause a pneumothorax. The chest tube should be maintained to the
underwater seal at all times.
DIF: Cognitive Level: Apply
REF: p. 654
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
SHORT ANSWER
1. A nurse is interpreting the results of a child’s peak expiratory flow rate. Which percentage,
either at this number or less than this number, is considered to be a red zone? (Record your
answer in a whole number.)
ANS:
50
A peak expiratory flow rate of red (<50% of personal best) signals a medical alert. Severe
airway narrowing may be occurring. A short-acting bronchodilator should be administered.
Notify the practitioner if the peak expiratory flow rate does not return immediately and stay
in yellow or green zones.
DIF: Cognitive Level: Analyze
REF: p. 666
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
OTHER
1. The nurse enters a room and finds a 6-year-old child who is unconscious. After calling for
help and before being able to use an automatic external defibrillator, which steps should the
nurse take? Place in correct order. Provide answer using lowercase letters separated by
commas (e.g., a, b, c, d, e, f).
a. Place on a hard surface.
b. Administer 30 chest compressions with two breaths.
c. Feel carotid pulse while maintaining head tilt with the other hand.
d. Use the head tilt–chin lift maneuver and check for breathing.
e. Place heel of one hand on lower half of sternum with other hand on top.
f. Give two rescue breaths.
ANS:
a, d, f, c, e, b
DIF: Cognitive Level: Analyze
REF: p. 682
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 22: The Child with Gastrointestinal Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which condition in a child should alert a nurse for increased fluid requirements?
a. Fever
b. Mechanical ventilation
c. Congestive heart failure
d. Increased intracranial pressure (ICP)
ANS: A
Fever leads to great insensible fluid loss in young children because of increased body surface
area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be
monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid
overload in children. Increased ICP does not lead to increased fluid requirements in children.
DIF: Cognitive Level: Understand
REF: p. 689
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that
melena, the passage of black, tarry stools, suggests bleeding from which area?
a. Perianal or rectal area
b. Hemorrhoids or anal fissures
c. Upper gastrointestinal (GI) tract
d. Lower GI tract
ANS: C
Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood
from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.
DIF: Cognitive Level: Apply
REF: p. 696
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. Which type of dehydration is defined as “dehydration that occurs in conditions in which
electrolyte and water deficits are present in approximately balanced proportion”?
Isotonic dehydration
Hypotonic dehydration
Hypertonic dehydration
All types of dehydration in infants and small children
a.
b.
c.
d.
ANS: A
Isotonic dehydration is the correct term for this definition and is the most frequent form of
dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds
the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water
loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of
water or a larger intake of electrolytes. This definition is specific to isotonic dehydration.
DIF: Cognitive Level: Understand
REF: p. 694
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A nurse is admitting an infant with dehydration caused from water loss in excess of
electrolyte loss. Which type of dehydration is this infant experiencing?
Isotonic
Isosmotic
Hypotonic
Hypertonic
a.
b.
c.
d.
ANS: D
Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most
dangerous type of dehydration. It is caused by feeding children fluids with high amounts of
solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are
present in balanced proportion and is another term for isomotic dehydration. Hypotonic
dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum
hypotonic.
DIF: Cognitive Level: Understand
REF: p. 694
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. An infant is brought to the emergency department with dehydration. Which physical
assessment finding does the nurse expect?
a.
b.
c.
d.
Weight gain
Bradycardia
Poor skin turgor
Brisk capillary refill
ANS: C
Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and
tachycardia. The infant would have prolonged capillary refill, not brisk.
DIF: Cognitive Level: Understand
REF: p. 691
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The
nurse should further ask the parents if the toddler has which associated factor that is causing
the acute diarrhea?
a. Celiac disease
b. Antibiotic therapy
c. Immunodeficiency
d. Protein malnutrition
ANS: B
Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may
be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and
may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency
would occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic
diarrhea from lowered resistance to infection.
DIF: Cognitive Level: Apply
REF: p. 691
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children?
a. Giardia organisms
b. Shigella organisms
c. Rotavirus
d. Salmonella organisms
ANS: C
Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia
(parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial
pathogen that is uncommon in the United States.
DIF: Cognitive Level: Understand
REF: p. 697
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which is a parasite that causes acute diarrhea?
a. Shigella organisms
b. Salmonella organisms
c. Giardia lamblia
d. Escherichia coli
ANS: C
G. lamblia is a parasite that represents 10% of non-dysenteric illness in the United States.
Shigella, Salmonella, and E. coli are bacterial pathogens.
DIF: Cognitive Level: Understand
REF: p. 697
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen
confirm this diagnosis?
a. Eosinophils
b. Occult blood
c. pH less than 6
d. Neutrophils and red blood cells
ANS: D
Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance
and parasitic infections are suspected in the presence of eosinophils. Occult blood may
indicate pathogens such as Shigella, Campylobacter, or hemorrhagic Escherichia coli strains.
A pH of less than 6 may indicate carbohydrate malabsorption or secondary lactase
insufficiency.
DIF: Cognitive Level: Understand
REF: p. 700
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. Which therapeutic management should the nurse prepare to initiate first for a child with acute
diarrhea and moderate dehydration?
a. Clear liquids
b. Adsorbents, such as kaolin and pectin
c. Oral rehydration solution (ORS)
d. Antidiarrheal medications such as paregoric
ANS: C
ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they
contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended.
Antidiarrheals are not recommended because they do not get rid of pathogens.
DIF: Cognitive Level: Apply
REF: p. 700
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. A school-age child with diarrhea has been rehydrated. The nurse is discussing the child’s diet
with the family. Which statement by the parent would indicate a correct understanding of the
teaching?
a. “I will keep my child on a clear liquid diet for the next 24 hours.”
b. “I should encourage my child to drink carbonated drinks but avoid food for the
next 24 hours.”
c. “I will offer my child bananas, rice, applesauce, and toast for the next 48 hours.”
d. “I should have my child eat a normal diet with easily digested foods for the next 48
hours.”
ANS: D
Easily digested foods such as cereals, cooked vegetables, and meats should be provided for
the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction
of a regular diet has no adverse effects and actually lessens the severity and duration of the
illness. Clear liquids and carbonated drinks have high carbohydrate content and few
electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. The
BRAT diet has little nutritional value and is high in carbohydrates.
DIF: Cognitive Level: Apply
REF: p. 700
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
12. A young child is brought to the emergency department with severe dehydration secondary to
acute diarrhea and vomiting. What should therapeutic management of this child begin with?
a. Intravenous (IV) fluids
b. ORS
c. Clear liquids, 1 to 2 ounces at a time
d. Administration of antidiarrheal medication
ANS: A
In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the
dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These
fluids have a high carbohydrate content, low electrolyte content, and high osmolality.
Antidiarrheal medications are not recommended for the treatment of acute infectious
diarrhea.
DIF: Cognitive Level: Apply
REF: p. 706
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been
giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse’s response should be
based on what knowledge about this drug?
a. Not indicated
b. Indicated because it slows intestinal motility
c. Indicated because it decreases diarrhea
d. Indicated because it decreases fluid and electrolyte losses
ANS: A
Antidiarrheal medications are not recommended for the treatment of acute infectious
diarrhea. These medications have adverse effects and toxicity, such as worsening of the
diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing
fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and
small children.
DIF: Cognitive Level: Analyze
REF: p. 701
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. Constipation has recently become a problem for a school-age girl. She is healthy except for
seasonal allergies that are being treated with antihistamines. What should the nurse suspect
caused the constipation?
a. Diet
b. Allergies
c. Antihistamines
d. Emotional factors
ANS: C
Constipation may be associated with drugs such as antihistamines, antacids, diuretics,
opioids, antiepileptics, and iron. Because this is the only known change in her habits, the
addition of antihistamines is most likely the cause of the diarrhea. With a change in bowel
habits, the role of any recently prescribed medications should be assessed.
DIF: Cognitive Level: Analyze
REF: p. 702
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. Which is a high-fiber food that the nurse should recommend for a child with chronic
constipation?
a. Raisins
b. Pancakes
c. Muffins
d. Ripe bananas
ANS: A
Raisins are a high-fiber food. Pancakes and muffins do not have significant fiber unless made
with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas,
have high fiber.
DIF: Cognitive Level: Apply
REF: p. 703
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
16. Which therapeutic management treatment is implemented for children with Hirschsprung
disease?
Daily enemas
Low-fiber diet
Permanent colostomy
Surgical removal of affected section of bowel
a.
b.
c.
d.
ANS: D
Most children with Hirschsprung disease require surgical rather than medical management.
Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and
restore normal bowel motility and function of the internal anal sphincter. Preoperative
management may include enemas and low-fiber, high-calorie, high-protein diet, until the
child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is
usually temporary.
DIF: Cognitive Level: Understand
REF: p. 703
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease.
What enema solution should be used?
Tap water
Normal saline
Oil retention
Phosphate preparation
a.
b.
c.
d.
ANS: B
Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is
not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid
overload. Oil-retention enemas will not achieve the “until clear” result. Phosphate enemas are
not advised for children because of the harsh action of the ingredients. The osmotic effects of
the phosphate enema can result in diarrhea, which can lead to metabolic acidosis.
DIF: Cognitive Level: Apply
REF: p. 703
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary
colostomy will be necessary. The nurse should recognize that preparing this child
psychologically is:
a. not necessary because of child’s age.
b. not necessary because colostomy is temporary.
c. necessary because it will be an adjustment.
d. necessary because the child must deal with a negative body image.
ANS: C
The child’s age dictates the type and extent of psychological preparation. When a colostomy
is performed, the child who is at least preschool age is told about the procedure and what to
expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old
child for procedures. The preschooler is not yet concerned with body image.
DIF: Cognitive Level: Understand
REF: p. 705
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
19. The nurse is explaining to a parent how to care for a school-age child with vomiting
associated with a viral illness. Which action should the nurse include?
a. Avoid carbohydrate-containing liquids.
b. Give nothing by mouth for 24 hours.
c. Brush teeth or rinse mouth after vomiting.
d. Give plain water until vomiting ceases for at least 24 hours.
ANS: C
It is important to emphasize the need for the child to brush the teeth or rinse the mouth after
vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Ad libitum
administration of glucose-electrolyte solution to an alert child will help restore water and
electrolytes satisfactorily. It is important to include carbohydrate to spare body protein and
avoid ketosis.
DIF: Cognitive Level: Apply
REF: p. 709
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other
complications. Which should the nurse suggest to minimize reflux?
a. Place in Trendelenburg position after eating.
b. Thicken formula with rice cereal.
c. Give continuous nasogastric tube feedings.
d. Give larger, less frequent feedings.
ANS: B
Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal
per ounce of formula have been recommended. Milk-thickening agents have been shown to
decrease the number of episodes of vomiting and to increase the caloric density of the
formula. This may benefit infants who are underweight as a result of GER disease. Placing
the child in a Trendelenburg position would increase the reflux. Continuous nasogastric
feedings are reserved for infants with severe reflux and failure to thrive.
DIF: Cognitive Level: Apply
REF: p. 726
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
21. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is
ordered for an infant with GER. What is the purpose of this medication?
Prevent reflux
Prevent hematemesis
Reduce gastric acid production
Increase gastric acid production
a.
b.
c.
d.
ANS: C
The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid
present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis
and increasing gastric acid production are not the modes of action of histamine-receptor
antagonists.
DIF: Cognitive Level: Understand
REF: p. 707
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
22. Which clinical manifestation would be the most suggestive of acute appendicitis?
a. Rebound tenderness
b. Bright red or dark red rectal bleeding
c. Abdominal pain that is relieved by eating
d. Abdominal pain that is most intense at McBurney point
ANS: D
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain
localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable
sign and is extremely painful to the child. Bright red or dark red rectal bleeding and
abdominal pain that is relieved by eating are not signs of acute appendicitis.
DIF: Cognitive Level: Understand
REF: p. 709
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. When caring for a child with probable appendicitis, the nurse should be alert to recognize that
which condition or symptom is a sign of perforation?
Bradycardia
Anorexia
Sudden relief from pain
Decreased abdominal distention
a.
b.
c.
d.
ANS: C
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation.
Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical
manifestation of appendicitis. Abdominal distention usually increases.
DIF: Cognitive Level: Understand
REF: p. 709
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis.
Which is appropriate to relieve the abdominal discomfort?
Place in Trendelenburg position.
Allow to assume position of comfort.
Apply moist heat to the abdomen.
Administer a saline enema to cleanse bowel.
a.
b.
c.
d.
ANS: B
The child should be allowed to take a position of comfort, usually with the legs flexed. The
Trendelenburg position will not help with the discomfort. In any instance in which
appendicitis is a possibility, there is a danger in administering a laxative or enemas or
applying heat to the area. Such measures stimulate bowel motility and increase the risk of
perforation.
DIF: Cognitive Level: Apply
REF: p. 709
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement
is most descriptive of Meckel diverticulum?
a. It is more common in females than in males.
b. It is acquired during childhood.
c. Intestinal bleeding may be mild or profuse.
d. Medical interventions are usually sufficient to treat the problem.
ANS: C
Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to
profuse intestinal bleeding. It is twice as common in males as in females, and complications
are more frequent in males. Meckel diverticulum is the most common congenital
malformation of the GI tract and is present in 1% to 4% of the general population. The
standard therapy is surgical removal of the diverticulum.
DIF: Cognitive Level: Apply
REF: p. 709
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. A nurse is admitting a child with Crohn disease. Parents ask the nurse, “How is this disease
different from ulcerative colitis?” Which statement should the nurse make when answering
this question?
a. “With Crohn disease the inflammatory process involves the whole GI tract.”
b. “There is no difference between the two diseases.”
c. “The inflammation with Crohn disease is limited to the colon and rectum.”
d. “Ulcerative colitis is characterized by skip lesions.”
ANS: A
The chronic inflammatory process of Crohn disease involves any part of the GI tract from the
mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers
of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa,
there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative
colitis is limited to the colon and rectum, with the distal colon and rectum the most severely
affected. Inflammation affects the mucosa and submucosa and involves continuous segments
along the length of the bowel with varying degrees of ulceration, bleeding, and edema.
DIF: Cognitive Level: Apply
REF: p. 713
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. Which is used to treat moderate to severe inflammatory bowel disease?
a. Antacids
b. Antibiotics
c. Corticosteroids
d. Antidiarrheal medications
ANS: C
Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the
inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal
medications are not drugs of choice in the treatment of inflammatory bowel disease.
Antibiotics may be used as an adjunctive therapy to treat complications.
DIF: Cognitive Level: Understand
REF: p. 713
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
28. Why are bismuth subsalicylate, clarithromycin, and metronidazole prescribed for a child with
a peptic ulcer?
Eradicate Helicobacter pylori
Coat gastric mucosa
Treat epigastric pain
Reduce gastric acid production
a.
b.
c.
d.
ANS: A
The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is
effective in the treatment of H. pylori and is prescribed to eradicate it.
DIF: Cognitive Level: Understand
REF: p. 716
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29. Which statement best characterizes hepatitis A?
a. Incubation period is 6 weeks to 6 months.
b. Principal mode of transmission is through the parenteral route.
c. Onset is usually rapid and acute.
d. There is a persistent carrier state.
ANS: C
Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is
characterized by a rapid and acute onset. The incubation period is approximately 3 weeks for
hepatitis A, and the principal mode of transmission for it is the fecal-oral route. Hepatitis A
does not have a carrier state.
DIF: Cognitive Level: Understand
REF: p. 717
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30. Which vaccine is now recommended for the immunization of all newborns?
a. Hepatitis A vaccine
b. Hepatitis B vaccine
c. Hepatitis C vaccine
d. Hepatitis A, B, and C vaccines
ANS: B
Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is
available for hepatitis A, but it is not yet universally recommended. No vaccine is currently
available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.
DIF: Cognitive Level: Understand
REF: p. 717
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
31. What offers the best chance of survival for a child with cirrhosis?
a. Liver transplantation
b. Treatment with corticosteroids
c. Treatment with immune globulin
d. Provision of nutritional support
ANS: A
The only successful treatment for end-stage liver disease and liver failure may be liver
transplantation, which has improved the prognosis for many children with cirrhosis. Liver
transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are
indications for transplantation. Liver transplantation reflects the failure of other medical and
surgical measures to prevent or treat cirrhosis.
DIF: Cognitive Level: Understand
REF: p. 719
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. A nurse is admitting an infant with biliary atresia. Which is the earliest clinical manifestation
of biliary atresia the nurse should expect to assess?
a. Jaundice
b. Vomiting
c. Hepatomegaly
d. Absence of stooling
ANS: A
Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in
the sclera and may be present at birth but is usually not apparent until age 2 to 3 weeks.
Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are
common but occur later. Stools are large and lighter in color than expected because of the
lack of bile.
DIF: Cognitive Level: Understand
REF: p. 719
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The
physician explained the plan of therapy and its expected good results. However, the mother
refuses to see or hold her baby. What is the initial therapeutic approach for the mother?
a. Restating what the physician has told her about plastic surgery.
b. Encouraging her to express her feelings.
c. Emphasizing the normalcy of her baby and the baby’s need for mothering.
d. Recognizing that negative feelings toward the child continue throughout
childhood.
ANS: B
For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must
emphasize not only the infant’s physical needs but also the parents’ emotional needs. The
mother needs to be able to express her feelings before she can accept her child. Although the
nurse will restate what the physician has told the mother about plastic surgery, it is not part of
the initial therapeutic approach. As the mother expresses her feelings, the nurse’s actions
should convey to the parents that the infant is a precious human being. The nurse emphasizes
the child’s normalcy and helps the mother recognize the child’s uniqueness.
DIF: Cognitive Level: Apply
REF: p. 723
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
34. What should be included in caring for the newborn with a cleft lip and palate before surgical
repair?
Gastrostomy feedings
Keeping infant in near-horizontal position during feedings
Allowing little or no sucking
Providing satisfaction of sucking needs
a.
b.
c.
d.
ANS: D
Using special or modified nipples for feeding techniques helps meet the infant’s sucking
needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the
infant’s head in an upright position. The child requires both nutritive and nonnutritive
sucking.
DIF: Cognitive Level: Apply
REF: p. 723
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
35. A mother who intended to breastfeed has given birth to an infant with a cleft palate. What
nursing interventions should be included?
Giving medication to suppress lactation.
Encouraging and helping mother to breastfeed.
Teaching mother to feed breast milk by gavage.
Recommending use of a breast pump to maintain lactation until infant can suck.
a.
b.
c.
d.
ANS: B
The mother who wishes to breastfeed may need encouragement and support because the
defect does present some logistical issues. The nipple must be positioned and stabilized well
back in the infant’s oral cavity so that the tongue action facilitates milk expression. Because
breastfeeding is an option, if the mother wishes to breastfeed, medications should not be
given to suppress lactation. Because breastfeeding can usually be accomplished, gavage
feedings are not indicated. The suction required to stimulate milk, absent initially, may be
useful before nursing to stimulate the let-down reflex.
DIF: Cognitive Level: Apply
REF: p. 724
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
36. The nurse is caring for an infant whose cleft lip was repaired. What important aspects of this
infant’s postoperative care should be included?
Arm restraints, postural drainage, mouth irrigations
Cleansing the suture line, supine and side-lying positions, arm restraints
Mouth irrigations, prone position, cleansing the suture line
Supine and side-lying positions, postural drainage, arm restraints
a.
b.
c.
d.
ANS: B
The suture line should be cleansed gently after feeding. The child should be positioned on the
back, on the side, or in an infant seat. Elbows are restrained to prevent the child from
accessing the operative site. Postural drainage is not indicated. This would increase the
pressure on the operative site when the child is placed in different positions. There is no
reason to perform mouth irrigations, and the child should not be placed in the prone position
where injury to the suture site can occur.
DIF: Cognitive Level: Apply
REF: p. 725
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37. During the first few days after surgery for cleft lip, which intervention should the nurse do?
a. Leave infant in crib at all times to prevent suture strain.
b. Keep infant heavily sedated to prevent suture strain.
c. Remove restraints periodically to cuddle infant.
d. Alternate position from prone to side-lying to supine.
ANS: C
Remove restraints periodically, while supervising the infant, to allow him or her to exercise
arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib,
but should be removed for appropriate holding and stimulation. Analgesia and sedation are
administered for pain. Heavy sedation is not indicated. The child should not be placed in the
prone position.
DIF: Cognitive Level: Apply
REF: p. 725
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
38. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What nursing
care should be included?
a. Elevate the head but give nothing by mouth.
b. Elevate the head for feedings.
c. Feed glucose water only.
d. Avoid suctioning unless infant is cyanotic.
ANS: A
When a newborn is suspected of having a tracheoesophageal fistula, the most desirable
position is supine with the head elevated on an inclined plane of at least 30 degrees. It is
imperative that any source of aspiration be removed at once; oral feedings are withheld.
Feedings should not be given to infants suspected of having tracheoesophageal fistulas. The
oral pharynx should be kept clear of secretion by oral suctioning. This is to prevent the
cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the
larynx.
DIF: Cognitive Level: Apply
REF: p. 725
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
39. Which type of hernia has an impaired blood supply to the herniated organ?
a. Hiatal hernia
b. Incarcerated hernia
c. Omphalocele
d. Strangulated hernia
ANS: D
A strangulated hernia is one in which the blood supply to the herniated organ is impaired.
Hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the
esophageal hiatus. Incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele
is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is
covered with peritoneum, not skin.
DIF: Cognitive Level: Understand
REF: p. 728
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40. What is the best description of pyloric stenosis?
a. Dilation of the pylorus
b. Hypertrophy of the pyloric muscle
c. Hypotonicity of the pyloric muscle
d. Reduction of tone in the pyloric muscle
ANS: B
Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter
becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of
the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle
are not the definition of pyloric stenosis.
DIF: Cognitive Level: Understand
REF: p. 728
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
41. Which observation made of the exposed abdomen is most indicative of pyloric stenosis?
a. Abdominal rigidity
b. Substernal retraction
c. Palpable olive-like mass
d. Marked distention of lower abdomen
ANS: C
The diagnosis of pyloric stenosis is often made after the history and physical examination.
The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the
abdominal muscles are relaxed. Abdominal rigidity and substernal retraction are usually not
present. The upper abdomen, not lower abdomen, is distended.
DIF: Cognitive Level: Understand
REF: p. 728
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
42. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation
would indicate pyloric stenosis?
Abdominal rigidity and pain on palpation
Rounded abdomen and hypoactive bowel sounds
Visible peristalsis and weight loss
Distention of lower abdomen and constipation
a.
b.
c.
d.
ANS: C
Visible gastric peristaltic waves that move from left to right across the epigastrium and
weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a
rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen,
not lower abdomen, is distended.
DIF: Cognitive Level: Apply
REF: p. 728
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
43. What are the results of excessive vomiting in an infant with pyloric stenosis?
a. Hyperchloremia
b. Hypernatremia
c. Metabolic acidosis
d. Metabolic alkalosis
ANS: D
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen
ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is
likely.
DIF: Cognitive Level: Understand
REF: p. 728
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
44. What is invagination of one segment of bowel within another called?
a. Atresia
b. Stenosis
c. Herniation
d. Intussusception
ANS: D
Intussusception occurs when a proximal section of the bowel telescopes into a more distal
segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in
lymphatic and venous obstruction. Invagination of one segment of bowel within another is
the definition of intussusception, not atresia, stenosis, or herniation.
DIF: Cognitive Level: Understand
REF: p. 728
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
45. The nurse is caring for a boy with probable intussusception. He had diarrhea before
admission but, while waiting for administration of air pressure to reduce the intussusception,
he passes a normal brown stool. Which nursing action is the most appropriate?
a. Notify practitioner
b. Measure abdominal girth
c. Auscultate for bowel sounds
d. Take vital signs, including blood pressure
ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is
immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic
care plan. The first action would be to report the normal stool to the practitioner.
DIF: Cognitive Level: Apply
REF: p. 728
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
46. Which is an important nursing consideration in the care of a child with celiac disease?
a. Refer to a nutritionist for detailed dietary instructions and education.
b. Help child and family understand that diet restrictions are usually only temporary.
c. Teach proper hand washing and standard precautions to prevent disease
transmission.
d. Suggest ways to cope more effectively with stress to minimize symptoms.
ANS: A
The main consideration is helping the child adhere to dietary management. Considerable time
is spent explaining to the child and parents about the disease process, the specific role of
gluten in aggravating the condition, and foods that must be restricted. Referral to a
nutritionist would help in this process. The most severe symptoms usually occur in early
childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not
transmissible or stress related.
DIF: Cognitive Level: Apply
REF: p. 732
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
47. An infant with short bowel syndrome will be discharged home on total parenteral nutrition
(TPN) and gastrostomy feedings. What should be included in the discharge teaching?
a. Prepare family for impending death.
b. Teach family signs of central venous catheter infection.
c. Teach family how to calculate caloric needs.
d. Secure TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.
ANS: B
During TPN therapy, care must be taken to minimize the risk of complications related to the
central venous access device, such as catheter infections, occlusions, or accidental removal.
This is an important part of family teaching. The prognosis for patients with short bowel
syndrome depends in part on the length of residual small intestine. It has improved with
advances in TPN. Although parents need to be taught about nutritional needs, the caloric
needs and prescribed TPN and rate are the responsibility of the health care team. The tubes
should not be placed under the diaper due to risk of infection.
DIF: Cognitive Level: Apply
REF: p. 727
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
48. A nurse is receiving report on a newborn admitted yesterday after a gastroschisis repair. In the
report, the nurse is told the newborn has a physician’s prescription for an NG tube to low
intermittent suction. The reporting nurse confirms that the NG tube is to low intermittent
suction and draining light green stomach contents. Upon initial assessment, the nurse notes
that the newborn has pulled the NG tube out. Which is the priority action the nurse should
take?
a. Replace the NG tube and continue the low intermittent suction.
b. Leave the NG tube out and notify the physician at the end of the shift.
c. Leave the NG tube out and monitor for bowel sounds.
d. Replace the NG tube, but leave to gravity drainage instead of low wall suction.
ANS: A
A newborn with a gastroschisis performed the day before will require bowel decompression
with an NG tube to low wall intermittent suction. The nurse’s priority action is to replace the
NG tube and continue with the low wall intermittent suctioning. The NG tube cannot be left
out this soon after surgery. The physician’s prescription was to have the NG tube to low wall
intermittent suction, so the tube cannot be placed to gravity drainage.
DIF: Cognitive Level: Apply
REF: p. 729
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
49. Parents of a child undergoing an endoscopy to rule out peptic ulcer disease (PUD) from H.
pylori ask the nurse, “If H. pylori is found, will my child need another endoscopy to know
that it is gone?” Which is the nurse’s best response?
a. “Yes, the only way to know the H. pylori has been eradicated is with another
endoscopy.”
b. “We can collect a stool sample and confirm that the H. pylori has been eradicated.”
c. “A blood test can be done to determine that the H. pylori is no longer present.”
d. “Your child will always test positive for H. pylori because after treatment it goes
into remission but can’t be completely eradicated.”
ANS: B
An upper endoscopy is the procedure initially performed to diagnose PUD. A biopsy can
determine the presence of H. pylori. Polyclonal and monoclonal stool antigen tests are an
accurate, noninvasive method to confirm H. pylori has been eradicated after treatment. A
blood test can identify the presence of the antigen to this organism, but because H. pylori was
already present, it would not be as accurate as a stool sample to determine whether it has been
eradicated. H. pylori can be treated and, once the treatment is complete, the stool sample can
determine that it was eradicated.
DIF: Cognitive Level: Apply
REF: p. 716
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
50. A child has recurrent abdominal pain (RAP) and a dairy-free diet has been prescribed for 2
weeks. Which explanation is the reason for prescribing a dairy-free diet?
To rule out lactose intolerance
To rule out celiac disease
To rule out sensitivity to high sugar content
To rule out peptic ulcer disease
a.
b.
c.
d.
ANS: A
Treatment for RAP involves providing reassurance and reducing or eliminating symptoms.
Dietary modifications may include removal of dairy products to rule out lactose intolerance.
Fructose is eliminated to rule out sensitivity to high sugar content, and gluten is removed to
rule out celiac disease. A dairy-free diet would not rule out peptic ulcer disease.
DIF: Cognitive Level: Understand
REF: p. 734
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
51. A family wants to begin oral feeding of their 4-year-old son, who is ventilator-dependent and
currently tube-fed. They ask the home health nurse to feed him the baby food orally. The
nurse recognizes a high risk of aspiration and an already compromised respiratory status.
What is the most appropriate nursing action?
a. Refuse to feed him orally because the risk is too high.
b. Explain the risks involved, and then let the family decide what should be done.
c. Feed him orally because the family has the right to make this decision for their
child.
d. Acknowledge their request, explain the risks, and explore with the family the
available options.
ANS: D
Parents want to be included in the decision making for their child’s care. The nurse should
discuss the request with the family to ensure this is the issue of concern, and then they can
explore potential options together. Merely refusing to feed the child orally does not determine
why the parents wish the oral feedings to begin and does not involve them in the problem
solving. The decision to begin or not change feedings should be a collaborative one, made in
consultation with the family, nurse, and appropriate member of the health care team.
DIF: Cognitive Level: Analyze
REF: p. 735
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
52. One of the supervisors for a home health agency asks the nurse to give the family a survey
evaluating the nurses and other service providers. How should the nurse interpret this
request?
a. Inappropriate, unless nurses are able to evaluate family.
b. Appropriate to improve quality of care.
c. Inappropriate, unless nurses and other providers agree to participate.
d. Inappropriate, because family lacks knowledge necessary to evaluate professionals.
ANS: B
Quality assessment and improvement activities are essential for virtually all organizations.
Family involvement is essential in evaluating a home care plan and can occur on several
levels. The nurse can ask the family open-ended questions at regular intervals to assess their
opinion of the effectiveness of care. Families should also be given an opportunity to evaluate
the individual home care nurses, the home care agency, and other service providers
periodically. The nurse is the care provider. The evaluation is of the provision of care to the
patient and family. The nurse’s role is not to evaluate the family. Quality-monitoring activities
are required by virtually all health care agencies. During the evaluation process, the family is
requested to provide their perceptions of care.
DIF: Cognitive Level: Apply
REF: p. 708
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
53. The home care nurse has been visiting an adolescent with recently acquired tetraplegia. The
teen’s mother tells the nurse, “I’m sick of providing all the care while my husband does
whatever he wants to, whenever he wants to do it.” Which should be the initial action of the
nurse?
a. Refer mother for counseling.
b. Listen and reflect mother’s feelings.
c. Ask father, in private, why he does not help.
d. Suggest ways the mother can get her husband to help.
ANS: B
It is appropriate for the nurse to reflect with the mother about her feelings, exploring issues
such as an additional home health aide to help care for the child and provide respite for the
mother. It is inappropriate for the nurse to agree with the mother that her husband is not
helping enough. It is a judgment beyond the role of the nurse and can undermine the family
relationship. Counseling is not necessary at this time. A support group for caregivers may be
indicated. Asking the father why he does not help and suggesting ways to the mother to get
her husband to help are interventions based on the mother’s assumption of minimal
contribution to the child’s care. The father may have a full-time job and other commitments.
The parents need to have an involved third person help them through the negotiation of
responsibilities for the loss of their normal child and new parenting responsibilities.
DIF: Cognitive Level: Apply
REF: p. 708
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. A child who has just had definitive repair of a high rectal malformation is to be discharged.
Which should the nurse address in the discharge preparation of this family? (Select all that
apply.)
a. Perineal and wound care
b. Necessity of firm stools to keep suture line clean
c. Bowel training beginning as soon as child returns home
d. Reporting any changes in stooling patterns to practitioner
e. Use of diet modification to prevent constipation
ANS: A, D, E
Wound care instruction is necessary in a child who is being discharged after surgery. The
parents are taught to notify the practitioner if any signs of an anal stricture or other
complications develop. Constipation is avoided, since a firm stool will place strain on the
suture line. Fiber and stool softeners are often given to keep stools soft and avoid tension on
the suture line. The child needs to recover from the surgical procedure. Then bowel training
may begin, depending on the child’s developmental and physiologic readiness.
DIF: Cognitive Level: Apply
REF: p. 732
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which is true concerning hepatitis B? (Select all that apply.)
a. Hepatitis B cannot exist in carrier state.
b. Hepatitis B can be prevented by HBV vaccine.
c. Hepatitis B can be transferred to an infant of a breastfeeding mother.
d. Onset of hepatitis B is insidious.
e. Principal mode of transmission for hepatitis B is fecal-oral route.
f. Immunity to hepatitis B occurs after one attack.
ANS: B, C, D, F
The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is
protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding
mother, especially if the mother’s nipples are cracked. The onset of hepatitis B is insidious.
Immunity develops after one exposure to hepatitis B. Hepatitis B has a carrier state. The
fecal-oral route is the principal mode of transmission for hepatitis A. Hepatitis B is
transmitted through the parenteral route.
DIF: Cognitive Level: Understand
REF: p. 717
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A nurse is planning preoperative care for a newborn with tracheoesophageal fistula (TEF).
Which interventions should the nurse plan to implement? (Select all that apply.)
a. Positioning with head elevated on a 30-degree plane
b. Feedings through a gastrostomy tube
c. Nasogastric tube to continuous low wall suction
d. Suctioning with a Replogle tube passed orally to the end of the pouch
e. Gastrostomy tube to gravity drainage
ANS: A, D, E
The most desirable position for a newborn who has TEF is supine (or sometimes prone) with
the head elevated on an inclined plane of at least 30 degrees. This positioning minimizes the
reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially
when intra-abdominal pressure is elevated. It is imperative to immediately remove any
secretions that can be aspirated. Until surgery, the blind pouch is kept empty by intermittent
or continuous suction through an indwelling double-lumen or Replogle catheter passed orally
or nasally to the end of the pouch. In some cases, a percutaneous gastrostomy tube is inserted
and left open so that any air entering the stomach through the fistula can escape, thus
minimizing the danger of gastric contents being regurgitated into the trachea. The
gastrostomy tube is emptied by gravity drainage. Feedings through the gastrostomy tube and
irrigations with fluid are contraindicated before surgery in an infant with a distal TEF. A
nasogastric tube to low intermittent suctioning could not be accomplished because the
esophagus ends in a blind pouch in TEF.
DIF: Cognitive Level: Apply
REF: p. 725
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which
prescribed orders should the nurse anticipate implementing? (Select all that apply.)
NPO for 24 hours
Administration of analgesics for pain
Ice bag to the incisional area
IV fluids continued until tolerating PO
Clear liquids as the first feeding
a.
b.
c.
d.
e.
ANS: B, D, E
Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear
liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until
the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should
be given around the clock because pain is continuous. Ice should not be applied to the
incisional area as it vasoconstricts and would reduce circulation to the incisional area and
impair healing.
DIF: Cognitive Level: Apply
REF: p. 728
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. A nurse is conducting dietary teaching on high-fiber foods for parents of a child with
constipation. Which foods should the nurse include as being high in fiber? (Select all that
apply.)
a. White rice
b. Avocados
c. Whole grain breads
d. Bran pancakes
e. Raw carrots
ANS: C, D, E
High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined
(brown) rice is high in fiber, but white rice is not. Raw fruits, especially those with skins or
seeds, other than ripe banana or avocado, are high in fiber.
DIF: Cognitive Level: Understand
REF: p. 732
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
SHORT ANSWER
1. A child has an NG tube to continuous low intermittent suction. The physician’s prescription is
to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour
period. The NG output for the previous 4 hours totaled 50 ml. What milliliter/hour rate should
the nurse administer to replace normal saline piggyback? (Record your answer in a whole
number.)
ANS:
25
The previous total 4-hour output was 50 ml. To run the 50 ml over a 2-hour period, the nurse
would divide 50 by 2 = 25. The normal saline replacement fluid would be run at 25 ml per
hour.
DIF: Cognitive Level: Apply
REF: p. 693
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
Chapter 23: The Child with Cardiovascular Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. A chest radiograph film is ordered for a child with suspected cardiac problems. The child’s
parent asks the nurse, “What will the radiograph show about the heart?” What knowledge
about the x-ray should the nurse include in the response to the parents?
a. Bones of chest but not the heart
b. Measurement of electrical potential generated from heart muscle
c. Permanent record of heart size and configuration
d. Computerized image of heart vessels and tissues
ANS: C
A chest radiograph will provide information on the heart size and pulmonary blood-flow
patterns. It will provide a baseline for future comparisons. The heart will be visible, as well as
the sternum and ribs. Electrocardiography (ECG) measures the electrical potential generated
from heart muscle. Echocardiography will produce a computerized image of the heart vessels
and tissues by using sound waves.
DIF: Cognitive Level: Understand
REF: p. 738
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is assessing a child after a cardiac catheterization. Which complication should the
nurse be assessing for?
Cardiac arrhythmia
Hypostatic pneumonia
Heart failure
Rapidly increasing blood pressure
a.
b.
c.
d.
ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias
occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart
failure, and rapidly increasing blood pressure are not risks usually associated with cardiac
catheterization.
DIF: Cognitive Level: Apply
REF: p. 739
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. José is a 4-year-old child scheduled for a cardiac catheterization. What should be included in
preoperative teaching?
Directed at his parents because he is too young to understand
Detailed in regard to the actual procedures so he will know what to expect
Done several days before the procedure so that he will be prepared
Adapted to his level of development so that he can understand
a.
b.
c.
d.
ANS: D
Preoperative teaching should always be directed at the child’s stage of development. The
caregivers also benefit from the same explanations. The parents may ask additional questions,
which should be answered, but the child needs to receive the information based on
developmental level. Preschoolers will not understand in-depth descriptions and should be
prepared close to the time of the cardiac catheterization.
DIF: Cognitive Level: Apply
REF: p. 739
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which explanation regarding cardiac catheterization is appropriate for a preschool child?
a. Postural drainage will be performed every 4 to 6 hours after the test.
b. It is necessary to be completely “asleep” during the test.
c. The test is short, usually taking less than 1 hour.
d. When the procedure is done, you will have to keep your leg straight for at least 4
hours.
ANS: D
The child’s leg will have to be maintained in a straight position for approximately 4 hours.
Younger children can be held in the parent’s lap with the leg maintained in the correct
position. Postural drainage will not be performed unless the child has corresponding
pulmonary problems. The child should be sedated to lie still, but being completely asleep is
not necessary. The test will vary in length of time from start to finish.
DIF: Cognitive Level: Apply
REF: p. 739
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The nurse is caring for a school-age child who has had a cardiac catheterization. The child
tells the nurse that the bandage is “too wet.” The nurse finds the bandage and bed soaked with
blood. What is the priority nursing action?
a. Notify physician
b. Apply new bandage with more pressure
c. Place the child in Trendelenburg position
d. Apply direct pressure above catheterization site
ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and
applying a new bandage can be done after pressure is applied. The nurse can have someone
else notify the physician while the pressure is being maintained. It is not a helpful
intervention to place the girl in the Trendelenburg position. It would increase the drainage
from the lower extremities.
DIF: Cognitive Level: Apply
REF: p. 739
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which
statement by the adolescent would indicate a need for further teaching?
a. “I should avoid tub baths but may shower.”
b. “I have to stay on strict bed rest for 3 days.”
c. “I should remove the pressure dressing the day after the procedure.”
d. “I may attend school but should avoid exercise for several days.”
ANS: B
The child does not need to be on strict bed rest for 3 days. Showers are recommended;
children should avoid a tub bath. The pressure dressing is removed the day after the
catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous
activity must be avoided for several days, but the child can return to school.
DIF: Cognitive Level: Analyze
REF: p. 740
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. What does the surgical closure of the ductus arteriosus do?
a. Stop the loss of unoxygenated blood to the systemic circulation
b. Decrease the edema in legs and feet
c. Increase the oxygenation of blood
d. Prevent the return of oxygenated blood to the lungs
ANS: D
The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lowerpressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no
additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary
artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher
pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary
circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not
directly affect the edema. Increasing the oxygenation of blood would not interfere with the
return of oxygenated blood to the lungs.
DIF: Cognitive Level: Analyze
REF: p. 740
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left
atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the
pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles.
Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great
arteries results in mixed blood flow.
DIF: Cognitive Level: Understand
REF: p. 743
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is conducting a staff in-service on congenital heart defects. Which structural defect
constitutes tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect,
overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial
stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy,
is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left
ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.
DIF: Cognitive Level: Understand
REF: p. 743
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect
results in decreased pulmonary blood flow?
a. Atrial septal defect
b. Tetralogy of Fallot
c. Ventricular septal defect
d. Patent ductus arteriosus
ANS: B
Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis
increases the pressure in the right ventricle, causing the blood to go from right to left across
the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus
result in increased pulmonary blood flow.
DIF: Cognitive Level: Understand
REF: p. 743
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. Which is best described as the inability of the heart to pump an adequate amount of blood to
the systemic circulation at normal filling pressures?
Pulmonary congestion
Congenital heart defect
Heart failure
Systemic venous congestion
a.
b.
c.
d.
ANS: C
The definition of heart failure is the inability of the heart to pump an adequate amount of
blood to the systemic circulation at normal filling pressures to meet the body’s metabolic
demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs.
Congenital heart defect is a malformation of the heart present at birth. Systemic venous
congestion is an excessive accumulation of fluid in the systemic vasculature.
DIF: Cognitive Level: Understand
REF: p. 744
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which is a clinical manifestation of the systemic venous congestion that can occur with heart
failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities
ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous
congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale,
cool extremities are clinical manifestations of impaired myocardial function.
DIF: Cognitive Level: Understand
REF: p. 744
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure
(HF). Which is a beneficial effect of administering digoxin (Lanoxin)?
It decreases edema.
It decreases cardiac output.
It increases heart size.
It increases venous pressure.
a.
b.
c.
d.
ANS: A
Digoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous
pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart
size and venous pressure are decreased by digoxin.
DIF: Cognitive Level: Understand
REF: p. 752
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which
drug should the nurse administer?
Captopril (Capoten)
Furosemide (Lasix)
Spironolactone (Aldactone)
Chlorothiazide (Diuril)
a.
b.
c.
d.
ANS: A
Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action
of aldosterone. Chlorothiazide works on the distal tubules.
DIF: Cognitive Level: Remember
REF: p. 752
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner
and withhold the medication if the apical pulse is less than _____ beats/min.
60
70
90
100
a.
b.
c.
d.
ANS: B
If a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld;
60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110
beats/min is the determination for not giving a digoxin dose to infants and young children.
DIF: Cognitive Level: Apply
REF: p. 752
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
16. A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner
and withhold the medication if the apical pulse is less than _______ beats/min.
60
70
90 to 110
110 to 120
a.
b.
c.
d.
ANS: C
If the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be given to a
6-month-old. Sixty beats/min is the cut-off for holding the digoxin dose in an adult; 70
beats/min is the determining heart rate to hold a dose of digoxin for an older child; 110 to 120
beats/min is an acceptable heart rate to administer digoxin to a 6-month-old.
DIF: Cognitive Level: Apply
REF: p. 752
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
17. The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common
sign of digoxin toxicity?
a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin
toxicity. The child will have a slower heart rate, not respiratory rate. The heart rate will be
slower, not faster.
DIF: Cognitive Level: Understand
REF: p. 754
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
18. The parents of a young child with heart failure tell the nurse that they are “nervous” about
giving digoxin (Lanoxin). The nurse’s response should be based on which statement?
It is a safe, frequently used drug.
It is difficult to either overmedicate or undermedicate with digoxin.
Parents lack the expertise necessary to administer digoxin.
Parents must learn specific, important guidelines for administration of digoxin.
a.
b.
c.
d.
ANS: D
Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and
lethal doses is very small. Specific guidelines are available for parents to learn how to
administer the drug safely and to monitor for side effects. Digoxin is a frequently used drug,
but it has a narrow therapeutic range. Small amounts of the liquid are given to infants,
making it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to
administer the drug at first, but with discharge preparation, they should be prepared to
administer the drug safely.
DIF: Cognitive Level: Apply
REF: p. 754
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which
statement about feeding the child is correct?
a. “You may need to increase the caloric density of your infant’s formula.”
b. “You should feed your baby every 2 hours.”
c. “You may need to increase the amount of formula your infant eats with each
feeding.”
d. “You should place a nasal oxygen cannula on your infant during and after each
feeding.”
ANS: A
The metabolic rate of infants with heart failure is greater because of poor cardiac function
and increased heart and respiratory rates. Their caloric needs are greater than those of the
average infants, yet their ability to take in the calories is diminished by their fatigue. Infants
with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough
rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the
heart failure. Infants do not require supplemental oxygen with feedings.
DIF: Cognitive Level: Apply
REF: p. 754
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As
part of teaching home care, the nurse encourages the family to give the child foods such as
bananas, oranges, and leafy vegetables. These foods are recommended because they are high
in which nutrient?
a. Chlorides
b. Potassium
c. Sodium
d. Vitamins
ANS: B
Diuretics that work on the proximal and distal renal tubules contribute to increased losses of
potassium. The child’s diet should be supplemented with this electrolyte. With this type of
diuretic, potassium must be monitored and supplemented as needed.
DIF: Cognitive Level: Understand
REF: p. 754
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
21. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the
priority nursing action?
a. Assess for neurologic defects
b. Place the child in the knee-chest position
c. Begin cardiopulmonary resuscitation
d. Prepare family for imminent death
ANS: B
The first action is to place the infant in the knee-chest position. Blow-by oxygen may be
indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing,
and circulation. Often, calming the child and administering oxygen and morphine can
alleviate the hypercyanotic spell.
DIF: Cognitive Level: Apply
REF: p. 759
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The
nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an
important objective to decrease this risk?
a. Minimize seizures
b. Prevent dehydration
c. Promote cardiac output
d. Reduce energy expenditure
ANS: B
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented
in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures,
promoting cardiac output, and reducing energy expenditure will not reduce the risk of
cerebrovascular accidents.
DIF: Cognitive Level: Analyze
REF: p. 759
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play
with other children because of possible overexertion. The nurse’s reply should be based on
which statement?
a. The child needs opportunities to play with peers.
b. The child needs to understand that peers’ activities are too strenuous.
c. Parents can meet all of the child’s needs.
d. Constant parental supervision is needed to avoid overexertion.
ANS: A
The child needs opportunities for social development. Children usually limit their activities if
allowed to set their own pace. The child will limit activities as necessary. Parents must be
encouraged to seek appropriate social activities for the child, especially before kindergarten.
The child needs to have activities that foster independence. The child will be able to regulate
activities.
DIF: Cognitive Level: Analyze
REF: p. 760
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
24. Which should the nurse consider when preparing a school-age child and the family for heart
surgery?
Unfamiliar equipment should not be shown.
Let the child hear the sounds of an ECG monitor.
Avoid mentioning postoperative discomfort and interventions.
Explain that an endotracheal tube will not be needed if the surgery goes well.
a.
b.
c.
d.
ANS: B
The child and family should be exposed to the sights and sounds of the intensive care unit
(ICU). All positive, nonfrightening aspects of the environment are emphasized. The child
should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare
the child for the postoperative experience, including intravenous (IV) lines, incision, and
endotracheal tube.
DIF: Cognitive Level: Analyze
REF: p. 763
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
25. Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which
action should the nurse take?
Keep child warm with blankets.
Apply a hypothermia blanket.
Record temperature on nurses’ notes.
Report findings to physician.
a.
b.
c.
d.
ANS: D
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100°
F) as part of the inflammatory response to tissue trauma. If the temperature is higher or
continues after this period, it is most likely a sign of an infection and immediate investigation
is indicated. Blankets should be removed from the child to keep the temperature from
increasing. Hypothermia blanket is not indicated for this level of temperature. The
temperature should be recorded, but the physician must be notified for evaluation. Suctioning
should be done only as indicated, not on a routine basis. The child should be suctioned for no
more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using
appropriate technique.
DIF: Cognitive Level: Apply
REF: p. 763
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. Which is an important nursing consideration when suctioning a young child who has had
heart surgery?
a. Perform suctioning at least every hour.
b. Suction for no longer than 30 seconds at a time.
c. Administer supplemental oxygen before and after suctioning.
d. Expect symptoms of respiratory distress when suctioning.
ANS: C
If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation
bag before and after the procedure to prevent hypoxia. Suctioning should be done only as
indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at
one time. Symptoms of respiratory distress are avoided by using appropriate technique.
DIF: Cognitive Level: Apply
REF: p. 764
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. The nurse is caring for a child after heart surgery. What should the nurse do if evidence of
cardiac tamponade is found?
Increase analgesia
Apply warming blankets
Immediately report this to physician
Encourage child to cough, turn, and breathe deeply
a.
b.
c.
d.
ANS: C
If evidence is noted of cardiac tamponade, which is blood or fluid in the pericardial space
constricting the heart, the physician is notified immediately of this life-threatening
complication. Increasing analgesia may be done before the physician drains the fluid, but the
physician must be notified. Warming blankets are not indicated at this time. Encouraging the
child to cough, turn, and breathe deeply should be deferred till after the evaluation by the
physician.
DIF: Cognitive Level: Apply
REF: p. 764
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. Which is an important nursing consideration when chest tubes will be removed from a child?
a. Explain that it is not painful.
b. Explain that only a Band-Aid will be needed.
c. Administer analgesics before the procedure.
d. Expect bright red drainage for several hours after removal.
ANS: C
It is appropriate to prepare the child for the removal of chest tubes with analgesics. Shortacting medications can be used that are administered through an existing IV line. A sharp,
momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze,
air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage
should be found on removal.
DIF: Cognitive Level: Apply
REF: p. 764
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29. Which is the most common causative agent of bacterial endocarditis?
a. Staphylococcus albus
b. Streptococcus hemolyticus
c. Staphylococcus albicans
d. Streptococcus viridans
ANS: D
S. viridans is the most common causative agent in bacterial (infective) endocarditis.
Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not
common causative agents.
DIF: Cognitive Level: Remember
REF: p. 765
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in
bacterial endocarditis?
Osler nodes
Janeway lesions
Subcutaneous nodules
Aschoff nodes
a.
b.
c.
d.
ANS: A
Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial
endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial
endocarditis. Subcutaneous nodules are nontender swellings, located over bony prominences,
commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells
and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.
DIF: Cognitive Level: Understand
REF: p. 766
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. What is the primary nursing intervention to prevent bacterial endocarditis?
a. Institute measures to prevent dental procedures.
b. Counsel parents of high-risk children about prophylactic antibiotics.
c. Observe children for complications, such as embolism and heart failure.
d. Encourage restricted mobility in susceptible children.
ANS: B
The objective of nursing care is to counsel the parents of high-risk children about both the
need for prophylactic antibiotics for dental procedures and the necessity of maintaining
excellent oral health. The child’s dentist should be aware of the child’s cardiac condition.
Dental procedures should be done to maintain a high level of oral health. Prophylactic
antibiotics are necessary. Children should be observed for complications such as embolism
and heart failure and restricted mobility should be encouraged in susceptible children, but
maintaining good oral health and prophylactic antibiotics is important.
DIF: Cognitive Level: Apply
REF: p. 765
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
32. Which is a common, serious complication of rheumatic fever?
a. Seizures
b. Cardiac arrhythmias
c. Pulmonary hypertension
d. Cardiac valve damage
ANS: D
Cardiac valve damage is the most significant complication of rheumatic fever. Seizures,
cardiac arrhythmias, and pulmonary hypertension are not common complications of
rheumatic fever.
DIF: Cognitive Level: Understand
REF: p. 767
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
33. The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a
major clinical manifestation of rheumatic fever?
Polyarthritis
Osler nodes
Janeway spots
Splinter hemorrhages of distal third of nails
a.
b.
c.
d.
ANS: A
Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation
of rheumatic fever. The affected joints will change every 1 to 2 days. Primarily the large
joints are affected. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of
infective endocarditis.
DIF: Cognitive Level: Apply
REF: p. 767
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. The nurse is admitting a child with rheumatic fever. Which therapeutic management should
the nurse expect to implement?
a. Administering penicillin
b. Avoiding salicylates (aspirin)
c. Imposing strict bed rest for 4 to 6 weeks
d. Administering corticosteroids if chorea develops
ANS: A
The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is
the drug of choice. Salicylates can be used to control the inflammatory process, especially in
the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile
stage, but it does not need to be strict. The chorea is transient and will resolve without
treatment.
DIF: Cognitive Level: Apply
REF: p. 768
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
35. Which action by the school nurse is important in the prevention of rheumatic fever?
a. Encourage routine cholesterol screenings.
b. Conduct routine blood pressure screenings.
c. Refer children with sore throats for throat cultures.
d. Recommend salicylates instead of acetaminophen for minor discomforts.
ANS: C
Nurses have a role in prevention—primarily in screening school-age children for sore throats
caused by group A b-hemolytic streptococci. They can achieve this by actively participating
in throat culture screening or by referring children with possible streptococcal sore throats for
testing. Cholesterol and blood pressure screenings do not facilitate the recognition and
treatment of group A b-hemolytic streptococci. Salicylates should be avoided routinely
because of the risk of Reye syndrome after viral illnesses.
DIF: Cognitive Level: Apply
REF: p. 768
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
36. When discussing hyperlipidemia with a group of adolescents, which high level labs should
the nurse explain can prevent cardiovascular disease?
Cholesterol
Triglycerides
Low-density lipoproteins (LDLs)
High-density lipoproteins (HDLs)
a.
b.
c.
d.
ANS: D
HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high
levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol,
triglycerides, and LDLs are not protective against cardiovascular disease.
DIF: Cognitive Level: Apply
REF: p. 768
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37. Which is the leading cause of death after heart transplantation?
a. Infection
b. Rejection
c. Cardiomyopathy
d. Heart failure
ANS: B
The posttransplant course is complex. The leading cause of death after cardiac transplantation
is rejection. Infection is a continued risk secondary to the immunosuppression necessary to
prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Heart
failure is not a leading cause of death.
DIF: Cognitive Level: Remember
REF: p. 775
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
38. When caring for the child with Kawasaki disease, the nurse should know which information?
a. A child’s fever is usually responsive to antibiotics within 48 hours.
b. The principal area of involvement is the joints.
c. Aspirin is contraindicated.
d. Therapeutic management includes administration of gamma globulin and aspirin.
ANS: D
High-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of
coronary artery abnormalities when given within the first 10 days of the illness. The fever of
Kawasaki disease is unresponsive to antibiotics and antipyretics. Mucous membranes,
conjunctiva, changes in the extremities, and cardiac involvement are seen. Aspirin is part of
the therapy.
DIF: Cognitive Level: Apply
REF: p. 776
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
39. The nurse is teaching nursing students about shock that occurs in children. What is one of the
most frequent causes of hypovolemic shock in children?
a. Sepsis
b. Blood loss
c. Anaphylaxis
d. Congenital heart disease
ANS: B
Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic
shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock
results from extreme allergy or hypersensitivity to a foreign substance. Congenital heart
disease contributes to hypervolemia, not hypovolemia.
DIF: Cognitive Level: Understand
REF: p. 778
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
40. Which type of shock is characterized by a hypersensitivity reaction causing massive
vasodilation and capillary leaks, which may occur with drug or latex allergy?
Neurogenic
Cardiogenic
Hypovolemic
Anaphylactic
a.
b.
c.
d.
ANS: D
Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance.
Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal
transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac
output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing
blood pressure, and low central venous pressure.
DIF: Cognitive Level: Understand
REF: p. 779
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
41. Which clinical manifestation should the nurse expect to see as shock progresses in a child and
becomes decompensated shock?
Thirst
Irritability
Apprehension
Confusion and somnolence
a.
b.
c.
d.
ANS: D
Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability,
and apprehension are signs of compensated shock.
DIF: Cognitive Level: Understand
REF: p. 779
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
42. Which occurs in septic shock?
a. Hypothermia
b. Increased cardiac output
c. Vasoconstriction
d. Angioneurotic edema
ANS: B
Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of
septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common
than vasoconstriction. Angioneurotic edema occurs as a manifestation in anaphylactic shock.
DIF: Cognitive Level: Understand
REF: p. 779
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
43. A child is brought to the emergency department experiencing an anaphylactic reaction to a
bee sting. While an airway is being established, the nurse should prepare which medication
for immediate administration?
a. Diphenhydramine (Benadryl)
b. Dobutamine (Dobutarex)
c. Epinephrine (Adrenalin)
d. Calcium chloride (calcium chloride)
ANS: C
After the first priority of establishing an airway, administration of epinephrine is the drug of
choice. Diphenhydramine, an antihistamine, is usually not used for severe reactions.
Dobutamine and calcium chloride are not appropriate drugs for this type of reaction.
DIF: Cognitive Level: Apply
REF: p. 780
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
44. What clinical manifestation is included in toxic shock syndrome?
a. Severe hypertension
b. Subnormal temperature
c. Erythematous macular rash
d. Papular rash over extremities
ANS: C
One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma.
Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic.
Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.
DIF: Cognitive Level: Understand
REF: p. 783
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
45. A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can
hold the child during the procedure. The nurse should answer with which response?
a. “You will be able to hold your child during the procedure.”
b. “Your child can be active during the procedure, but can’t sit in your lap.”
c. “Your child must lie quietly; sometimes a mild sedative is administered before the
procedure.”
d. “The procedure is invasive so your child will be restrained during the
echocardiogram.”
ANS: C
Although an echocardiogram is noninvasive, painless, and associated with no known side
effects, it can be stressful for children. The child must lie quietly in the standard
echocardiographic positions; crying, nursing, or sitting up often leads to diagnostic errors or
omissions. Therefore, infants and young children may need a mild sedative; older children
benefit from psychological preparation for the test. The distraction of a video or movie is
often helpful.
DIF: Cognitive Level: Apply
REF: p. 740
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
46. The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan
which intervention to decrease cardiac demands?
Organize nursing activities to allow for uninterrupted sleep.
Allow the infant to sleep through feedings during the night.
Wait for the infant to cry to show definite signs of hunger.
Discourage parents from rocking the infant
a.
b.
c.
d.
ANS: A
The infant requires rest and conservation of energy for feeding. Every effort is made to
organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible,
parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling
that help children sleep more soundly. To minimize disturbing the infant, changing bed linens
and complete bathing are done only when necessary. Feeding is planned to accommodate the
infant’s sleep and wake patterns. The child is fed at the first sign of hunger, such as when
sucking on fists, rather than waiting until he or she cries for a bottle because the stress of
crying exhausts the limited energy supply. Because infants with CHD tire easily and may
sleep through feedings, smaller feedings every 3 hours may be helpful.
DIF: Cognitive Level: Apply
REF: p. 740
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
47. The nurse is admitting a child with coarctation of the aorta. Which figure depicts this
congenital heart defect?
a.
b.
c.
d.
ANS: A
The figure that depicts a narrowing of the aortic arch is coarctation of the aorta. It typically
occurs past the ductal area but can occur in other areas along the aortic arch. The figure that
depicts an opening between the atria is atrial septal defect. The figure that depicts an opening
between the ventricles is ventricular septal defect. The figure that depicts an opening from the
atrium to the pulmonary artery is patent ductus arteriosus.
DIF: Cognitive Level: Analyze
REF: p. 746
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. Nursing interventions for the child after a cardiac catheterization should include which
actions? (Select all that apply.)
a. Allow ambulation as tolerated.
b. Monitor vital signs every 2 hours.
c. Assess the affected extremity for temperature and color.
d. Check pulses above the catheterization site for equality and symmetry.
e. Remove pressure dressing after 4 hours.
f. Maintain a patent peripheral intravenous catheter until discharge.
ANS: C, F
The extremity that was used for access for the cardiac catheterization must be checked for
temperature and color. Coolness and blanching may indicate arterial occlusion. The child
should have a patent peripheral intravenous line (PIV) to ensure adequate hydration. The
child should remain on bed rest with the leg extended for a minimum of 4 hours. Initially
vital signs are taken every 15 minutes, with emphasis on a heart rate counted for 1 minute.
Pulses above the catheterization site should not be affected by the catheterization. Pulses
distal to the site should be monitored. The pressure dressings should not be removed for 24
hours.
DIF: Cognitive Level: Apply
REF: p. 748
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which clinical manifestation should the nurse expect to see as shock progresses in a child and
becomes decompensated shock? (Select all that apply.)
a. Thirst and diminished urinary output
b. Irritability and apprehension
c. Cool extremities and decreased skin turgor
d. Confusion and somnolence
e. Normal blood pressure and narrowing pulse pressure
f. Tachypnea and poor capillary refill time
ANS: C, D, F
Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor
capillary refill time are beginning signs of decompensated shock. Thirst, diminished urinary
output, irritability, apprehension, normal blood pressure, and narrowing pulse pressure are
signs of compensated shock.
DIF: Cognitive Level: Analyze
REF: p. 779
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. The nurse is conducting discharge teaching about signs and symptoms of heart failure to
parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the
nurse include? (Select all that apply.)
a. Warm flushed extremities
b. Weight loss
c. Decreased urinary output
d. Sweating (inappropriate)
e. Fatigue
ANS: C, D, E
The signs and symptoms of heart failure include decreased urinary output, sweating, and
fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain,
not weight loss.
DIF: Cognitive Level: Apply
REF: p. 741
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
SHORT ANSWER
1. Which is the highest acceptable mg/dl level of low density lipoprotein (LDL) cholesterol for
a child from a family with heart disease? (Record your answer in a whole number.)
ANS:
110
The low-density lipoproteins (LDLs) contain low concentrations of triglycerides, high levels
of cholesterol, and moderate levels of protein. LDL is the major carrier of cholesterol to the
cells. Cells use cholesterol for synthesis of membranes and steroid production. Elevated
circulating LDL is a strong risk factor in cardiovascular disease. For children from families
with a history of heart disease, the LDL should be <110.
DIF: Cognitive Level: Apply
REF: p. 768
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
OTHER
1. An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during
a routine blood draw. Which interventions should the nurse implement? Place in order from
the highest-priority intervention to the lowest-priority intervention. Provide the answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Administer 100% oxygen by blow-by.
b. Place the infant in knee-chest position.
c. Remain calm.
d. Give morphine subcutaneously or by an existing intravenous line.
ANS:
b, a, d, c
Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen
in infants with tetralogy of Fallot, may occur in any child whose heart defect includes
obstruction to pulmonary blood flow and communication between the ventricles. The infant
becomes acutely cyanotic and hyperpneic because sudden infundibular spasm decreases
pulmonary blood flow and increases right-to-left shunting. Because profound hypoxemia
causes cerebral hypoxia, hypercyanotic spells require prompt assessment and treatment to
prevent brain damage or possibly death. The infant should first be placed in the knee-chest
position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate the
hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, the nurse
should remain calm.
DIF: Cognitive Level: Apply
REF: p. 741
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. A child is brought to the emergency department experiencing an anaphylactic reaction to a
bee sting. Once the airway is established, the nurse should do which action? Place in correct
sequence. Provide the answer using lowercase letters separated by commas (e.g., a, b, c).
a. Administer epinephrine.
b. Keep the child warm and calm.
c. Obtain vascular access.
ANS:
c, a, b
The correct sequence of actions is to obtain vascular access, administer epinephrine, and then
to keep the child warm and calm.
DIF: Cognitive Level: Apply
REF: p. 781
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 24: The Child with Hematologic or Immunologic Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which child should the nurse document as being anemic?
a. 7-year-old child with a hemoglobin of 11.5 g/dl
b. 3-year-old child with a hemoglobin of 12 g/dl
c. 14-year-old child with a hemoglobin of 10 g/dl
d. 1-year-old child with a hemoglobin of 13 g/dl
ANS: D
Anemia is a condition in which the number of red blood cells, or hemoglobin concentration,
is reduced below the normal values for age. Anemia is defined as a hemoglobin level below
10 or 11 g/dl. The child with a hemoglobin of 10 g/dl would be considered anemic. The
normal hemoglobin for a child after 2 years of age is 11.5 to 15.5 g/dl.
DIF: Cognitive Level: Understand
REF: p. 789
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Several blood tests are ordered for a preschool child with severe anemia. The child is crying
and upset because of memories of the venipuncture done at the clinic 2 days ago. What
should the nurse explain?
a. The venipuncture discomfort is very brief
b. Only one venipuncture will be needed
c. A topical application of local anesthetic can eliminate venipuncture pain
d. Most blood tests on children require only a finger puncture because a small amount
of blood is needed
ANS: C
Preschool children are concerned with both pain and the loss of blood. When preparing the
child for venipuncture, the nurse will use a topical anesthetic to eliminate any pain. This is a
traumatic experience for preschool children. They are concerned about their bodily integrity.
A local anesthetic should be used, and a bandage should be applied to maintain bodily
integrity. The nurse should not promise one attempt in case multiple attempts are required.
Both finger punctures and venipunctures are traumatic for children. Both require preparation.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is planning activity for a 4-year-old child with anemia. Which activity should the
nurse plan for this child?
a. Game of “hide and seek” in the children’s outdoor play area
b. Participation in dance activities in the playroom
c. Puppet play in the child’s room
d. A walk down to the hospital lobby
ANS: C
Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an
important nursing responsibility is to assess the child’s energy level and minimize excess
demands. The child’s level of tolerance for activities of daily living and play is assessed, and
adjustments are made to allow as much self-care as possible without undue exertion. Puppet
play in the child’s room would not be overly tiring. Hide and seek, dancing, and walking to
the lobby would not conserve the anemic child’s energy.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is teaching parents about the importance of iron in a toddler’s diet. Which explains
why iron-deficiency anemia is common during toddlerhood?
Milk is a poor source of iron.
Iron cannot be stored during fetal development.
Fetal iron stores are depleted by age 1 month.
Dietary iron cannot be started until age 12 months.
a.
b.
c.
d.
ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cow’s milk is a
major component of their diet and it is a poor source of iron. Iron is stored during fetal
development, but the amount stored depends on maternal iron stores. Fetal iron stores are
usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, ironfortified formula, and cereals during the first 12 months of life.
DIF: Cognitive Level: Understand
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is teaching parents of an infant about the causes of iron-deficiency anemia. Which
statement best describes iron-deficiency anemia in infants?
It is caused by depression of the hematopoietic system.
It is easily diagnosed because of an infant’s emaciated appearance.
Clinical manifestations are similar regardless of the cause of the anemia.
Clinical manifestations result from a decreased intake of milk and the preterm
addition of solid foods.
a.
b.
c.
d.
ANS: C
In iron-deficiency anemia, the child’s clinical appearance is a result of the anemia, not the
underlying cause. Usually the hematopoietic system is not depressed in iron-deficiency
anemia. The bone marrow produces red cells that are smaller and contain less hemoglobin
than normal red cells. Children who are iron deficient from drinking excessive quantities of
milk are usually pale and overweight. They are receiving sufficient calories, but are deficient
in essential nutrients. The clinical manifestations result from decreased intake of ironfortified solid foods and an excessive intake of milk.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. Which should the nurse include when teaching the mother of a 9-month-old infant about
administering liquid iron preparations?
They should be given with meals.
They should be stopped immediately if nausea and vomiting occur.
Adequate dosage will turn the stools a tarry green color.
Allow preparation to mix with saliva and bathe the teeth before swallowing.
a.
b.
c.
d.
ANS: C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the
iron dose is adequate, the stools will become a tarry green color. The lack of the color change
may indicate insufficient iron. The iron should be given in two divided doses between meals
when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic
environment. Vomiting and diarrhea may occur with iron administration. If these occur, the
iron should be given with meals, and the dosage reduced, then gradually increased as the
child develops tolerance. Liquid preparations of iron stain the teeth. They should be
administered through a straw and the mouth rinsed after administration.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. Iron dextran is ordered for a young child with severe iron-deficiency anemia. What nursing
considerations should be included?
a. Administer with meals
b. Administer between meals
c. Inject deeply into a large muscle
d. Massage injection site for 5 minutes after administration of drug
ANS: C
Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be
injected into a large muscle. Iron dextran is for intramuscular or intravenous (IV)
administration. The site should not be massaged to prevent leakage, potential irritation, and
staining of the skin.
DIF: Cognitive Level: Apply
REF: p. 790
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
8. The nurse is recommending how to prevent iron-deficiency anemia in a healthy, term,
breastfed infant. Which should be suggested?
a. Iron (ferrous sulfate) drops after age 1 month
b. Iron-fortified commercial formula by age 4 to 6 months
c. Iron-fortified infant cereal by age 2 months
d. Iron-fortified infant cereal by age 4 to 6 months
ANS: D
Breast milk supplies inadequate iron for growth and development after age 5 months.
Supplementation is necessary at this time. The mother can supplement the breastfeeding with
iron-fortified infant cereal. Iron supplementation or the introduction of solid foods in a
breastfed baby is not indicated. Providing iron-fortified commercial formula by age 4 to 6
months should be done only if the mother is choosing to discontinue breastfeeding.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. Parents of a child with sickle cell anemia ask the nurse, “What happens to the hemoglobin in
sickle cell anemia?” Which statement by the nurse explains the disease process?
a. Normal adult hemoglobin is replaced by abnormal hemoglobin.
b. There is a lack of cellular hemoglobin being produced.
c. There is a deficiency in the production of globulin chains.
d. The size and depth of the hemoglobin are affected.
ANS: A
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in
which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a
lack of cellular elements being produced. Thalassemia major refers to a variety of inherited
disorders characterized by deficiencies in production of certain globulin chains. Irondeficiency anemia affects the size, depth, and color of hemoglobin.
DIF: Cognitive Level: Apply
REF: p. 791
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. When both parents have sickle cell trait, which is the chance their children will have sickle
cell anemia?
a. 25%
b. 50%
c. 75%
d. 100%
ANS: A
Sickle cell anemia is inherited in an autosomal recessive pattern. If both parents have sickle
cell trait (one copy of the sickle cell gene), then for each pregnancy, a 25% chance exists that
their child will be affected with sickle cell disease. With each pregnancy, a 50% chance exists
that the child will have sickle cell trait. Percentages of 75% and 100% are too high for the
children of parents who have sickle cell trait.
DIF: Cognitive Level: Analyze
REF: p. 791
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. The nurse is conducting a staff in-service on sickle cell anemia. Which describes the
pathologic changes of sickle cell anemia?
a. Sickle-shaped cells carry excess oxygen.
b. Sickle-shaped cells decrease blood viscosity.
c. Increased red blood cell destruction occurs.
d. Decreased adhesion of sickle-shaped cells occurs.
ANS: C
The clinical features of sickle cell anemia are primarily the result of increased red blood cell
destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells
have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of
low oxygen tension. When the sickle cells change shape, they increase the viscosity in the
area where they are involved in the microcirculation. Increased adhesion and entanglement of
cells occurs.
DIF: Cognitive Level: Apply
REF: p. 791
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which clinical manifestation should the nurse expect when a child with sickle cell anemia
experiences an acute vasoocclusive crisis?
a. Circulatory collapse
b. Cardiomegaly, systolic murmurs
c. Hepatomegaly, intrahepatic cholestasis
d. Painful swelling of hands and feet; painful joints
ANS: D
A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the
extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain
resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances
occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic
murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive
phenomena.
DIF: Cognitive Level: Understand
REF: p. 791
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. Why is meperidine (Demerol) not recommended for children in sickle cell crisis?
a. May induce seizures
b. Is easily addictive
c. Not adequate for pain relief
d. Given by intramuscular injection
ANS: A
A metabolite of meperidine, normeperidine, is a central nervous system stimulant that
produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with
repetitive dosing. Patients with sickle cell disease are particularly at risk for normeperidineinduced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is
adequate for pain relief. It is available for IV infusion.
DIF: Cognitive Level: Understand
REF: p. 795
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. A school-age child is admitted in vasoocclusive sickle cell crisis. What should be included in
the child’s care?
a. Correction of acidosis
b. Adequate hydration and pain management
c. Pain management and administration of heparin
d. Adequate oxygenation and replacement of factor VIII
ANS: B
The management of crises includes adequate hydration, minimization of energy expenditures,
pain management, electrolyte replacement, and blood component therapy if indicated.
Hydration and pain control are two of the major goals of therapy. The acidosis will be
corrected as the crisis is treated. Heparin and factor VIII are not indicated in the treatment of
vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in
reversing sickling because it cannot reach the clogged blood vessels.
DIF: Cognitive Level: Apply
REF: p. 796
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. The parents of a child hospitalized with sickle cell anemia tell the nurse that they are
concerned about narcotic analgesics causing addiction. Which is appropriate for the nurse to
explain about narcotic analgesics?
a. Are often ordered but not usually needed
b. Rarely cause addiction because they are medically indicated
c. Are given as a last resort because of the threat of addiction
d. Are used only if other measures, such as ice packs, are ineffective
ANS: B
The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild to
moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are
indicated, they are titrated to effect and are given around the clock. Patient-controlled
analgesia reinforces the patient’s role and responsibility in managing the pain and provides
flexibility in dealing with pain. Few, if any, patients who receive opioids for severe pain
become behaviorally addicted to the drug. Narcotics are often used because of the severe
nature of the pain of vasoocclusive crisis. Ice is contraindicated because of its
vasoconstrictive effects.
DIF: Cognitive Level: Apply
REF: p. 796
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
16. Which statement best describes b-thalassemia major (Cooley anemia)?
a. All formed elements of the blood are depressed.
b. Inadequate numbers of red blood cells are present.
c. Increased incidence occurs in families of Mediterranean extraction.
d. Increased incidence occurs in persons of West African descent.
ANS: C
Individuals who live near the Mediterranean Sea and their descendants have the highest
incidence of thalassemia. An overproduction of red cells occurs. Although numerous, the red
cells are relatively unstable. Sickle cell disease is common in persons of West African
descent.
DIF: Cognitive Level: Understand
REF: p. 799
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. Chelation therapy is begun on a child with b-thalassemia major. What is the purpose of this
therapy?
Treat the disease
Eliminate excess iron
Decrease risk of hypoxia
Manage nausea and vomiting
a.
b.
c.
d.
ANS: B
A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation
therapy with deferoxamine (an iron-chelating agent) is given with oral supplements of
vitamin C to increase iron excretion. Chelation therapy treats the side effect of the disease
management. Decreasing the risk of hypoxia and managing nausea and vomiting are not the
purposes of chelation therapy.
DIF: Cognitive Level: Understand
REF: p. 799
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
18. In which of the conditions are all the formed elements of the blood simultaneously
depressed?
Aplastic anemia
Sickle cell anemia
Thalassemia major
Iron-deficiency anemia
a.
b.
c.
d.
ANS: A
Aplastic anemia refers to a bone marrow–failure condition in which the formed elements of
the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which
normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin.
Thalassemia major is a group of blood disorders characterized by deficiency in the
production rate of specific hemoglobin globin chains. Iron-deficiency anemia results in a
decreased amount of circulating red cells.
DIF: Cognitive Level: Understand
REF: p. 800
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
19. What is a possible cause of acquired aplastic anemia in children?
a. Drugs
b. Injury
c. Deficient diet
d. Congenital defect
ANS: A
Drugs, such as chemotherapeutic agents and several antibiotics (e.g., chloramphenicol), can
cause aplastic anemia. Injury, deficient diet, and congenital defect are not causative agents in
acquired aplastic anemia.
DIF: Cognitive Level: Understand
REF: p. 800
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
20. Parents of a hemophiliac child ask the nurse, “Can you describe hemophilia to us?” Which
response by the nurse is descriptive of most cases of hemophilia?
a. Autosomal dominant disorder causing deficiency in a factor involved in the blood-
clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged
bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become moonshaped
ANS: C
The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The
two most common forms of the disorder are factor VIII deficiency, hemophilia A or classic
hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. The inheritance
pattern is X-linked recessive. The disorder involves coagulation factors, not platelets, and
does not involve red cells or the Y chromosomes.
DIF: Cognitive Level: Understand
REF: p. 801
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse is conducting a staff in-service on childhood blood disorders. Which describes the
pathology of idiopathic thrombocytopenic purpura?
Bone marrow failure in which all elements are suppressed
Deficiency in the production rate of globin chains
Diffuse fibrin deposition in the microvasculature
An excessive destruction of platelets
a.
b.
c.
d.
ANS: D
Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an
excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and a
normal bone marrow. Aplastic anemia refers to a bone marrow–failure condition in which the
formed elements of the blood are simultaneously depressed. Thalassemia major is a group of
blood disorders characterized by deficiency in the production rate of specific hemoglobin
globin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin
deposition in the microvasculature, consumption of coagulation factors, and endogenous
generation of thrombin and plasma.
DIF: Cognitive Level: Understand
REF: p. 804
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. Which is caused by a virus that primarily infects a specific subset of T lymphocytes, the
CD4+ T cells?
a. Wiskott-Aldrich syndrome
b. Idiopathic thrombocytopenic purpura
c. Acquired immunodeficiency syndrome (AIDS)
d. Severe combined immunodeficiency disease
ANS: C
AIDS is caused by the human immunodeficiency virus (HIV), which primarily attacks the
CD4+ T cells. Wiskott-Aldrich syndrome, idiopathic thrombocytopenic purpura, and severe
combined immunodeficiency disease are not viral illnesses.
DIF: Cognitive Level: Remember
REF: p. 806
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral
drugs. What is the purpose of these drugs?
Cure the disease
Delay disease progression
Prevent spread of disease
Treat Pneumocystis carinii pneumonia
a.
b.
c.
d.
ANS: B
Although not a cure, these antiviral drugs can suppress viral replication, preventing further
deterioration of the immune system and delaying disease progression. At this time, cure is not
possible. These drugs do not prevent the spread of the disease. P. carinii prophylaxis is
accomplished with antibiotics.
DIF: Cognitive Level: Understand
REF: p. 806
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
24. Which immunization should be given with caution to children infected with human
immunodeficiency virus (HIV)?
a. Influenza
b. Varicella
c. Pneumococcal
d. Inactivated poliovirus (IPV)
ANS: B
The children should be carefully evaluated before being given live viral vaccines such as
varicella, measles, mumps, and rubella. The child must be immunocompetent and not have
contact with other severely immunocompromised individuals. Influenza, pneumococcal, and
inactivated poliovirus (IPV) are not live vaccines.
DIF: Cognitive Level: Apply
REF: p. 806
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
25. The nurse is planning care for an adolescent with AIDS. Which is the priority nursing goal?
a. Preventing infection
b. Preventing secondary cancers
c. Restoring immunologic defenses
d. Identifying source of infection
ANS: A
Because the child is immunocompromised in association with HIV infection, the prevention
of infection is paramount. Although certain precautions are justified in limiting exposure to
infection, these must be balanced with the concern for the child’s normal developmental
needs. Preventing secondary cancers is not currently possible. Current drug therapy is
affecting the disease progression; although not a cure, these drugs can suppress viral
replication, preventing further deterioration. Case finding is not a priority nursing goal.
DIF: Cognitive Level: Apply
REF: p. 806
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. The school nurse is informed that a child with human immunodeficiency virus (HIV) will be
attending school soon. Which is an important nursing intervention?
a. Carefully follow universal precautions.
b. Determine how the child became infected.
c. Inform the parents of the other children.
d. Reassure other children that they will not become infected.
ANS: A
Universal precautions are necessary to prevent further transmission of the disease. It is not
the role of the nurse to determine how the child became infected. Informing the parents of
other children and reassuring children that they will not become infected is a violation of the
child’s right to privacy.
DIF: Cognitive Level: Apply
REF: p. 807
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. The nurse is conducting a staff in-service on inherited childhood blood disorders. Which
statement describes severe combined immunodeficiency syndrome (SCIDS)?
a. There is a deficit in both the humoral and cellular immunity with this disease.
b. Production of red blood cells is affected with this disease.
c. Adult hemoglobin is replaced by abnormal hemoglobin in this disease.
d. There is a deficiency of T and B lymphocyte production with this disease.
ANS: A
Severe combined immunodeficiency syndrome (SCIDS) is a genetic disorder that results in
deficits of both humoral and cellular immunity. Wiskott-Aldrich is an X-linked recessive
disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary
disorder of red cell production. Sickle cell disease is characterized by the replacement of
adult hemoglobin with an abnormal hemoglobin S.
DIF: Cognitive Level: Understand
REF: p. 809
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. Several complications can occur when a child receives a blood transfusion. Which is an
immediate sign or symptom of an air embolus?
a. Chills and shaking
b. Nausea and vomiting
c. Irregular heart rate
d. Sudden difficulty in breathing
ANS: D
Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and
apprehension. Air emboli should be avoided by carefully flushing all tubing of air before
connecting to patient. Chills, shaking, nausea, and vomiting are associated with hemolytic
reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia.
DIF: Cognitive Level: Understand
REF: p. 810
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
29. An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has
developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough.
Of what are these manifestations most suggestive?
a. Air emboli
b. Allergic reaction
c. Hemolytic reaction
d. Circulatory overload
ANS: D
The signs of circulatory overload include distended neck veins, hypertension, crackles, dry
cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing,
sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria,
pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are
characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in
chest, flank pain, red or black urine, and progressive signs of shock and renal failure.
DIF: Cognitive Level: Apply
REF: p. 811
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. The nurse is reviewing first aid with a group of school nurses. Which statement made by a
participant indicates a correct understanding of the information?
a. “If a child loses a tooth due to injury, I should place the tooth in warm milk.”
b. “If a child has recurrent abdominal pain, I should send him or her back to class
until the end of the day.”
c. “If a child has a chemical burn to the eye, I should irrigate the eye with normal
saline.”
d. “If a child has a nosebleed, I should have the child sit up and lean forward.”
ANS: D
If a child has a nosebleed, the child should lean forward, not lie down. A tooth should be
placed in cold milk or saliva for transporting to a dentist. Recurrent abdominal pain is a
physiologic problem and requires further evaluation. If a chemical burn occurs in the eye, the
eye should be irrigated with water for 20 minutes.
DIF: Cognitive Level: Apply
REF: p. 805
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The nurse is planning care for a school-age child admitted to the hospital with hemophilia.
Which interventions should the nurse plan to implement for this child? (Select all that apply.)
Finger sticks for blood work instead of venipunctures
Avoidance of IM injections
Acetaminophen (Tylenol) for mild pain control
Soft tooth brush for dental hygiene
Administration of packed red blood cells
a.
b.
c.
d.
e.
ANS: B, C, D
Nurses should take special precautions when caring for a child with hemophilia to prevent the
use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is
substituted for IM injections whenever possible. Venipunctures for blood samples are usually
preferred for these children. There is usually less bleeding after the venipuncture than after
finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be
used. Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A
soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums.
Packed red blood cells are not administered. The primary therapy for hemophilia is
replacement of the missing clotting factor. The products available are factor VIII
concentrates.
DIF: Cognitive Level: Apply
REF: p. 806
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Parents of a school-age child with hemophilia ask the nurse, “Which sports are recommended
for children with hemophilia?” Which sports should the nurse recommend? (Select all that
apply.)
a. Soccer
b. Swimming
c. Basketball
d. Golf
e. Bowling
ANS: B, D, E
Because almost all persons with hemophilia are boys, the physical limitations in regard to
active sports may be a difficult adjustment, and activity restrictions must be tempered with
sensitivity to the child’s emotional and physical needs. Use of protective equipment, such as
padding and helmets, is particularly important, and noncontact sports, especially swimming,
walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sports such as
soccer and basketball are not recommended.
DIF: Cognitive Level: Apply
REF: p. 801
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which should the nurse teach about prevention of sickle cell crises to parents of a preschool
child with sickle cell disease? (Select all that apply.)
Limit fluids at bedtime.
Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs.
Give penicillin as prescribed.
Use ice packs to decrease the discomfort of vasoocclusive pain in the legs.
Notify the health care provider if your child begins to develop symptoms of a cold.
a.
b.
c.
d.
e.
ANS: B, C, E
The most important issues to teach the family of a child with sickle cell anemia are to (1)
seek early intervention for problems, such as a fever of 38.5° C (101.3° F) or greater; (2) give
penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as
respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse
emphasizes the importance of adequate hydration to prevent sickling and to delay the
adhesion–stasis–thrombosis–ischemia cycle. It is not sufficient to advise parents to “force
fluids” or “encourage drinking.” They need specific instructions on how many daily glasses
or bottles of fluid are required. Many foods are also a source of fluid, particularly soups,
flavored ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with
impaired kidney function result in the problem of enuresis. Parents who are unaware of this
fact frequently use the usual measures to discourage bedwetting, such as limiting fluids at
night. Enuresis is treated as a complication of the disease, such as joint pain or some other
symptom, to alleviate parental pressure on the child. Ice should not be used during a
vasoocclusive pain crisis because it vasoconstricts and impairs circulation even more.
DIF: Cognitive Level: Apply
REF: p. 797
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit
signs of a transfusion reaction. Place in order the interventions the nurse should implement
sequencing from the highest priority to the lowest. Provide the answer using lowercase letters
separated by commas (e.g., a, b, c, d).
a. Take the vital signs.
b. Stop the transfusion.
c. Notify the practitioner.
d. Maintain a patent IV line with normal saline.
ANS:
b, a, d, c
If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs,
maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do
not restart the transfusion until the child’s condition has been medically evaluated.
DIF: Cognitive Level: Apply
REF: p. 811
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 25: The Child with Cancer
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The school nurse is discussing testicular self-examination with adolescent boys. Why is this
important?
a. Epididymitis is common during adolescence.
b. Asymptomatic sexually transmitted diseases may be present.
c. Testicular tumors during adolescence are generally malignant.
d. Testicular tumors, although usually benign, are common during adolescence.
ANS: C
Tumors of the testes are not common, but when manifested in adolescence, they are generally
malignant and demand immediate evaluation. Epididymitis is not common in adolescence.
Asymptomatic sexually transmitted disease would not be evident during testicular selfexamination. The focus of this examination is on testicular cancer. Testicular tumors are most
commonly malignant.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which is the usual presenting symptom for testicular cancer?
a. Hard, painful mass
b. Hard, painless mass
c. Epididymis easily palpated
d. Scrotal swelling and pain
ANS: B
The usual presenting symptom for testicular cancer is a heavy, hard, painless mass that is
either smooth or nodular and palpated on the testes. A hard, painful mass, an epididymis
easily palpated, and scrotal swelling and pain are not the clinical presentations of testicular
cancer.
DIF: Cognitive Level: Understand
REF: p. 842
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which is most descriptive of the pathophysiology of leukemia?
a. Increased blood viscosity occurs.
b. Thrombocytopenia (excessive destruction of platelets) occurs.
c. Unrestricted proliferation of immature white blood cells (WBCs) occurs.
d. First stage of coagulation process is abnormally stimulated.
ANS: C
Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is
defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of
the body. Increased blood viscosity may occur secondary to the increased number of WBCs.
Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.
The coagulation process is unaffected by leukemia.
DIF: Cognitive Level: Understand
REF: p. 826
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A boy with leukemia screams whenever he needs to be turned or moved. Which is the most
probable cause of this pain?
a. Edema
b. Bone involvement
c. Petechial hemorrhages
d. Changes within the muscles
ANS: B
The invasion of the bone marrow with leukemic cells gradually causes a weakening of the
bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing
pressure causes severe pain. Edema, petechial hemorrhages, and changes within the muscles
would not cause severe pain.
DIF: Cognitive Level: Analyze
REF: p. 826
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Myelosuppression, associated with chemotherapeutic agents or some malignancies such as
leukemia, can cause bleeding tendencies because of a(n):
decrease in leukocytes.
increase in lymphocytes.
vitamin C deficiency.
decrease in blood platelets.
a.
b.
c.
d.
ANS: D
The decrease in blood platelets secondary to the myelosuppression of chemotherapy can
cause an increase in bleeding. The child and family should be alerted to avoid risk of injury.
Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect
bleeding tendencies.
DIF: Cognitive Level: Apply
REF: p. 828
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate,
cytarabine, and hydrocortisone. What will the triple intrathecal chemotherapy prevent?
Infection
Brain tumor
Drug side effects
Central nervous system (CNS) disease
a.
b.
c.
d.
ANS: D
For certain children, CNS prophylactic therapy is indicated. This drug regimen is used to
prevent CNS leukemia and will not prevent infection or drug side effects. If the child has a
brain tumor in addition to leukemia, additional therapy would be indicated.
DIF: Cognitive Level: Analyze
REF: p. 831
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. A young boy will receive a bone marrow transplant (BMT). This is possible because one of
his older siblings is a histocompatible donor. Which is this type of BMT called?
Syngeneic
Allogeneic
Monoclonal
Autologous
a.
b.
c.
d.
ANS: B
Allogeneic transplants are from another individual. Because he and his sibling are
histocompatible, the BMT can be done. Syngeneic marrow is from an identical twin. There is
no such thing as a monoclonal BMT. Autologous refers to the individual’s own marrow.
DIF: Cognitive Level: Understand
REF: p. 824
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which is the most effective pain-management approach for a child who is having a bone
marrow aspiration?
a. Relaxation techniques
b. Administration of an opioid
c. EMLA cream applied over site
d. Conscious or unconscious sedation
ANS: D
Effective pharmacologic and nonpharmacologic measures should be used to minimize pain
associated with procedures. For bone marrow aspiration, conscious or unconscious sedation
should be used. Relaxation, opioids, and EMLA can be used to augment the conscious or
unconscious sedation.
DIF: Cognitive Level: Apply
REF: p. 824
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
9. Which immunization should not be given to a child receiving chemotherapy for cancer?
a. Tetanus vaccine
b. Inactivated poliovirus vaccine
c. Diphtheria, pertussis, tetanus (DPT)
d. Measles, rubella, mumps
ANS: D
The vaccine used for measles, mumps, and rubella is a live virus and can result in an
overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and diphtheria,
pertussis, tetanus (DPT) are not live virus vaccines.
DIF: Cognitive Level: Apply
REF: p. 825
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
10. Which is often administered to prevent or control hemorrhage in a child with cancer?
a. Nitrosoureas
b. Platelets
c. Whole blood
d. Corticosteroids
ANS: B
Most bleeding episodes can be prevented or controlled with the administration of platelet
concentrate or platelet-rich plasma. Nitrosoureas, whole blood, and corticosteroids would not
prevent or control hemorrhage.
DIF: Cognitive Level: Apply
REF: p. 826
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
11. The nurse is administering an IV chemotherapeutic agent to a child with leukemia. The child
suddenly begins to wheeze and have severe urticaria. Which is the most appropriate nursing
action?
a. Stop drug infusion immediately.
b. Recheck rate of drug infusion.
c. Observe child closely for next 10 minutes.
d. Explain to child that this is an expected side effect.
ANS: A
If an allergic reaction is suspected, the drug should be immediately discontinued. Any drug in
the line should be withdrawn, and a normal saline infusion begun to keep the line open.
Rechecking the rate of drug infusion, observing the child closely for next 10 minutes, and
explaining to the child that this is an expected side effect can all be done after the drug
infusion is stopped and the child is evaluated.
DIF: Cognitive Level: Apply
REF: p. 826
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
12. A school-age child with leukemia experienced severe nausea and vomiting when receiving
chemotherapy for the first time. Which is the most appropriate nursing action to prevent or
minimize these reactions with subsequent treatments?
a. Encourage drinking large amounts of favorite fluids.
b. Encourage child to take nothing by mouth (remain NPO) until nausea and
vomiting subside.
c. Administer an antiemetic before chemotherapy begins.
d. Administer an antiemetic as soon as child has nausea.
ANS: C
The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy
is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent
anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and
vomiting. Waiting until nausea and vomiting subside will help with this episode, but the child
will have the discomfort and be at risk for dehydration. Administering an antiemetic as soon
as the child has nausea does not prevent anticipatory nausea.
DIF: Cognitive Level: Apply
REF: p. 826
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest
that the parents try which intervention?
a. Relax any eating pressures.
b. Firmly insist that child eat normally.
c. Begin gavage feedings to supplement diet.
d. Serve foods that are either hot or cold.
ANS: A
A multifaceted approach is necessary for children with severe stomatitis and anorexia. First,
the parents should relax eating pressures. The nurse should suggest that the parents try soft,
bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. The stomatitis
is a temporary condition. The child can resume good food habits as soon as the condition
resolves.
DIF: Cognitive Level: Apply
REF: p. 826
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. The nurse is preparing a child for possible alopecia from chemotherapy. Which should be
included?
Explain to child that hair usually regrows in 1 year.
Advise child to expose head to sunlight to minimize alopecia.
Explain to child that wearing a hat or scarf is preferable to wearing a wig.
Explain to child that when hair regrows, it may have a slightly different color or
texture.
a.
b.
c.
d.
ANS: D
Alopecia is a side effect of certain chemotherapeutic agents. When the hair regrows, it may
be a different color or texture. The hair usually grows back within 3 to 6 months after
cessation of treatment. The head should be protected from sunlight to avoid sunburn.
Children should choose the head covering they prefer.
DIF: Cognitive Level: Apply
REF: p. 819
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. Which is a common clinical manifestation of Hodgkin disease?
a. Petechiae
b. Bone and joint pain
c. Painful, enlarged lymph nodes
d. Enlarged, firm, nontender lymph nodes
ANS: D
Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common
presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and
joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful.
DIF: Cognitive Level: Understand
REF: p. 829
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that
the bone marrow will be administered by which route?
Bone grafting
Bone marrow injection
IV infusion
Intra-abdominal infusion
a.
b.
c.
d.
ANS: C
Bone marrow from a donor is infused intravenously, and the transfused stem cells will
repopulate the marrow. Because the stem cells migrate to the recipient’s marrow when given
intravenously, this is the method of administration.
DIF: Cognitive Level: Apply
REF: p. 818
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding
associated with this tumor?
Abdominal swelling
Weight gain
Hypotension
Increased urinary output
a.
b.
c.
d.
ANS: A
The initial assessment finding with a Wilms (kidney) tumor is abdominal swelling. Weight
loss, not weight gain, may be a finding. Hypertension occasionally occurs with a Wilms
tumor. Urinary output is not increased, but hematuria may be noted.
DIF: Cognitive Level: Understand
REF: p. 820
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. What is the most common clinical manifestation(s) of brain tumors in children?
a. Irritability
b. Seizures
c. Headaches and vomiting
d. Fever and poor fine motor control
ANS: C
Headaches, especially on awakening, and vomiting that is not related to feeding are the most
common clinical manifestation(s) of brain tumors in children. Irritability, seizures, and fever
and poor fine motor control are clinical manifestations of brain tumors, but headaches and
vomiting are the most common.
DIF: Cognitive Level: Understand
REF: p. 831
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
19. A 5-year-old boy is being prepared for surgery to remove a brain tumor. Nursing actions
should be based on which statement?
a. Removal of tumor will stop the various symptoms.
b. Usually the postoperative dressing covers the entire scalp.
c. He is not old enough to be concerned about his head being shaved.
d. He is not old enough to understand the significance of the brain.
ANS: B
The child should be told what he will look and feel like after surgery. This includes the size of
the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing.
Some of the symptoms may be alleviated by the removal of the tumor, but postsurgical
headaches and cerebellar symptoms such as ataxia may be aggravated. Children should be
prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if
the child is awake. Children at this age have poorly defined body boundaries and little
knowledge of internal organs. Intrusive experiences are frightening, especially those that
disrupt the integrity of the skin.
DIF: Cognitive Level: Apply
REF: p. 831
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. The nurse is teaching nursing students about childhood nervous system tumors. Which best
describes a neuroblastoma?
a. Diagnosis is usually made after metastasis occurs.
b. Early diagnosis is usually possible because of the obvious clinical manifestations.
c. It is the most common brain tumor in young children.
d. It is the most common benign tumor in young children.
ANS: A
Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is
made after metastasis occurs, with the first signs caused by involvement in the nonprimary
site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most
common malignant extracranial solid tumors in children. The majority of tumors develop in
the adrenal glands or the retroperitoneal sympathetic chain. They are not benign but
metastasize.
DIF: Cognitive Level: Apply
REF: p. 835
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse is monitoring a 7-year-old child post surgical resection of an infratentorial brain
tumor. Which vital sign findings indicate Cushing’s triad?
Increased temperature, tachycardia, tachypnea
Decreased temperature, bradycardia, bradypnea
Bradycardia, hypertension, irregular respirations
Bradycardia, hypotension, tachypnea
a.
b.
c.
d.
ANS: C
Cushing’s triad is a hallmark sign of increased intracranial pressure (ICP). The triad includes
bradycardia, hypertension, and irregular respirations. Increased or decreased temperature is
not a sign of Cushing’s triad.
DIF: Cognitive Level: Understand
REF: p. 831
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. In which position should the nurse place a 10-year-old child after a large tumor was removed
through a supratentorial craniotomy?
a. On the inoperative side with the bed flat
b. On the inoperative side with the head of bed elevated 20 to 30 degrees
c. On the operative side with the bed flat and pillows behind the head
d. On the operative side with the head of bed elevated 45 degrees
ANS: B
If a large tumor was removed, the child is not placed on the operative side because the brain
may suddenly shift to that cavity, causing trauma to the blood vessels, linings, and the brain
itself. The child with an infratentorial procedure is usually positioned on either side with the
bed flat. When a supratentorial craniotomy is performed, the head of bed is elevated 20 to 30
degrees with the child on either side or on the back. In a supratentorial craniotomy, the head
elevation facilitates CSF drainage and decreases excessive blood flow to the brain to prevent
hemorrhage. Pillows should be placed against the child’s back, not head, to maintain the
desired position.
DIF: Cognitive Level: Apply
REF: p. 831
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. A nurse is conducting a staff in-service on childhood cancers. Which is the primary site of
osteosarcoma?
a. Femur
b. Humerus
c. Pelvis
d. Tibia
ANS: A
Osteosarcoma is the most frequently encountered malignant bone cancer in children. The
peak incidence is between ages 10 and 25 years. More than half occur in the femur. After the
femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.
DIF: Cognitive Level: Understand
REF: p. 836
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
24. The nurse is taking care of an adolescent with osteosarcoma. The parents ask the nurse about
treatment. The nurse should make which accurate response about treatment for
osteosarcoma?
a. Treatment usually consists of surgery and chemotherapy.
b. Amputation of the affected extremity is rarely necessary.
c. Intensive irradiation is the primary treatment.
d. Bone marrow transplantation offers the best chance of long-term survival.
ANS: A
The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy.
Intensive irradiation and bone marrow transplantation are usually not part of the therapeutic
management.
DIF: Cognitive Level: Understand
REF: p. 836
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. An adolescent with osteosarcoma is scheduled for a leg amputation in 2 days. The nurse’s
approach should include which action?
a. Answering questions with straightforward honesty
b. Avoiding discussing the seriousness of the condition
c. Explaining that, although the amputation is difficult, it will cure the cancer
d. Assisting the adolescent in accepting the amputation as better than a long course of
chemotherapy
ANS: A
Honesty is essential to gain the child’s cooperation and trust. The diagnosis of cancer should
not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or
she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be
answered. To accept the need for radical surgery, the child must be aware of the lack of
alternatives for treatment. Amputation is necessary, but it will not guarantee a cure.
Chemotherapy is an integral part of the therapy with surgery. The child should be informed of
the need for chemotherapy and its side effects before surgery.
DIF: Cognitive Level: Apply
REF: p. 836
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
26. The nurse is caring for an adolescent with osteosarcoma being admitted to undergo
chemotherapy. The adolescent had a right above-the-knee amputation 2 months ago and has
been experiencing “phantom limb pain.” Which prescribed medication is appropriate to
administer to relieve phantom limb pain?
a. Amitriptyline (Elavil)
b. Hydrocodone (Vicodin)
c. Oxycodone (OxyContin)
d. Alprazolam (Xanax)
ANS: A
Amitriptyline (Elavil) has been used successfully to decrease phantom limb pain. Opioids
such as Vicodin or OxyContin would not be prescribed for this pain. A benzodiazepine,
Xanax, would not be prescribed for this type of pain.
DIF: Cognitive Level: Apply
REF: p. 836
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
27. Home care is being considered for a young child who is ventilator-dependent. Which factor is
most important in deciding whether home care is appropriate?
Level of parents’ education
Presence of two parents in the home
Preparation and training of family
Family’s ability to assume all health care costs
a.
b.
c.
d.
ANS: C
One of the essential elements is the family’s training and preparation. The family must be
able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed
that nursing care will be available on a continual basis, and the family will have to care for
the child. The amount of formal education reached by the parents is not the important issue.
The determinant is the family’s ability to care adequately for the child in the home. At least
two family members should learn and demonstrate all aspects of the child’s care in the
hospital, but it does not have to be two parents. Few families can assume all health care costs.
Creative financial planning, including negotiating arrangements with the insurance company
and/or public programs, may be required.
DIF: Cognitive Level: Analyze
REF: p. 842
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
28. The home health nurse asks a child’s mother many questions as part of the assessment. The
mother answers many questions and then stops and says, “I don’t know why you ask me all
this. Who gets to know this information?” The nurse should take which action?
a. Determine why the mother is so suspicious.
b. Determine what the mother does not want to tell.
c. Explain who will have access to the information.
d. Explain that everything is confidential and that no one else will know what is said.
ANS: C
Communication with the family should not be invasive. The nurse needs to explain the
importance of collecting the information, its applicability to the child’s care, and who will
have access to the information. The mother is not being suspicious and is not necessarily
withholding important information. She has a right to understand how the information she
provides will be used. The nurse will need to share, through both oral and written
communication, clinically relevant information with other involved health professionals.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
29. When communicating with other professionals, it is important for home care nurses to:
a. ask others what they want to know.
b. share everything known about the family.
c. restrict communication to clinically relevant information.
d. recognize that confidentiality is not possible.
ANS: C
The nurse will need to share, through both oral and written communication, clinically
relevant information with other involved health professionals. Asking others what they want
to know and sharing everything known about the family is inappropriate. Patients have a right
to confidentiality. The nurse is not permitted to share information about clients, except
clinically relevant information that pertains to the child’s care. Confidentiality permits the
disclosure of information to other health professionals on a need-to-know basis.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
30. The home health nurse is caring for a child who requires complex care. The family expresses
frustration related to obtaining accurate information about their child’s illness and its
management. Which is the best action for the nurse?
a. Determine why family is easily frustrated.
b. Refer family to child’s primary care practitioner.
c. Clarify family’s request, and provide information they want.
d. Answer only questions that family needs to know about.
ANS: C
The philosophic basis for family-centered practice is the recognition that the family is the
constant in the child’s life. It is essential and appropriate that the family have complete and
accurate information about their child’s illness and management. The nurse may first have to
clarify what information the family believes has not been communicated. The family’s
frustration arises from their perception that they are not receiving information pertinent to
their child’s care. Referring the family to the child’s primary care practitioner does not help
the family. The home health nurse should have access to the necessary information. Questions
about what they need and want to know concerning their child’s care should be addressed.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
31. A family wants to begin oral feeding of their 4-year-old son, who is ventilator-dependent and
currently tube-fed. They ask the home health nurse to feed him the baby food orally. The
nurse recognizes a high risk of aspiration and an already compromised respiratory status. The
most appropriate nursing action is to:
a. refuse to feed him orally because the risk is too high.
b. explain the risks involved, and then let the family decide what should be done.
c. feed him orally because the family has the right to make this decision for their
child.
d. acknowledge their request, explain the risks, and explore with the family the
available options.
ANS: D
Parents want to be included in the decision making for their child’s care. The nurse should
discuss the request with the family to ensure this is the issue of concern, and then they can
explore potential options together. Merely refusing to feed the child orally does not determine
why the parents wish the oral feedings to begin and does not involve them in the problem
solving. The decision to begin or not change feedings should be a collaborative one, made in
consultation with the family, nurse, and appropriate member of the health care team.
DIF: Cognitive Level: Analyze
REF: p. 823
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
32. One of the supervisors for a home health agency asks the nurse to give the family a survey
evaluating the nurses and other service providers. The nurse should recognize this as:
inappropriate, unless nurses are able to evaluate family.
appropriate to improve quality of care.
inappropriate, unless nurses and other providers agree to participate.
inappropriate, because family lacks knowledge necessary to evaluate professionals.
a.
b.
c.
d.
ANS: B
Quality assessment and improvement activities are essential for virtually all organizations.
Family involvement is essential in evaluating a home care plan and can occur on several
levels. The nurse can ask the family open-ended questions at regular intervals to assess their
opinion of the effectiveness of care. Families should also be given an opportunity to evaluate
the individual home care nurses, the home care agency, and other service providers
periodically. The nurse is the care provider. The evaluation is of the provision of care to the
patient and family. The nurse’s role is not to evaluate the family. Quality-monitoring activities
are required by virtually all health care agencies. During the evaluation process, the family is
requested to provide their perceptions of care.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
33. The home care nurse has been visiting an adolescent with recently acquired tetraplegia. The
teen’s mother tells the nurse, “I’m sick of providing all the care while my husband does
whatever he wants to, whenever he wants to do it.” Which should be the initial action of the
nurse?
a. Refer mother for counseling.
b. Listen and reflect mother’s feelings.
c. Ask father, in private, why he does not help.
d. Suggest ways the mother can get her husband to help.
ANS: B
It is appropriate for the nurse to reflect with the mother about her feelings, exploring issues
such as an additional home health aide to help care for the child and provide respite for the
mother. It is inappropriate for the nurse to agree with the mother that her husband is not
helping enough. It is a judgment beyond the role of the nurse and can undermine the family
relationship. Counseling is not necessary at this time. A support group for caregivers may be
indicated. Asking the father why he does not help and suggesting ways to the mother to get
her husband to help are interventions based on the mother’s assumption of minimal
contribution to the child’s care. The father may have a full-time job and other commitments.
The parents need to have an involved third person help them through the negotiation of
responsibilities for the loss of their normal child and new parenting responsibilities.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
34. A mother of a 5-year-old child, with complex health care needs and cared for at home,
expresses anxiety about attending a kindergarten graduation exercise of a neighbor’s child.
The mother says, “I wish it could be my child graduating from kindergarten.” The nurse
recognizes that the mother is experiencing:
a. abnormal anxiety.
b. ineffective coping.
c. chronic sorrow.
d. denial.
ANS: C
Home care nurses should be aware that parents may experience chronic sorrow as a parental
stressor. Chronic sorrow as a normal grief response is associated with a living loss (the loss of
a healthy child) that is cyclical in nature. This is a normal response and does not indicate
abnormal anxiety, ineffective coping, or denial.
DIF: Cognitive Level: Understand
REF: p. 842
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
35. A ventilator-dependent child is cared for at home by his parents. Nurses come for 4 hours
each day giving the parents some relief. Which other strategy should the nurse recommend to
give the parents a break from the responsibilities of caring for a ventilator-dependent child?
a. Encourage members from the parent’s church group to provide some relief care.
b. Train a trusted grandparent to provide an occasional break from the responsibilities
of care.
c. Encourage the parents to pay out of pocket for additional private duty nurses.
d. Suggest the parents place the child in a care facility.
ANS: B
Respite care provides temporary relief to parents and allows a break from the responsibilities
of caring for the ventilator-dependent child on a daily basis. For example, a trusted and
trained grandparent or extended family member may be called in to give the family a break
from caring for the child. Members of the parent’s church group would not have the training
necessary to care for a ventilator-dependent child. Asking the parents to pay out of pocket for
additional care would put a financial burden on the family. Suggesting the family place the
child in a care facility is inappropriate.
DIF: Cognitive Level: Apply
REF: p. 842
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. The nurse is preparing to give oral care to a school-age child with mucositis secondary to
chemotherapy administered to treat leukemia. Which preparations should the nurse use for
oral care on this child? (Select all that apply.)
a. Chlorhexidine gluconate (Peridex)
b. Lemon glycerin swabs
c. Antifungal troches (lozenges)
d. Lip balm (Aquaphor)
e. Hydrogen peroxide
ANS: A, C, D
Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate
(Peridex) because of its dual effectiveness against candidal and bacterial infections,
antifungal troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips
moist. Agents that should not be used include lemon glycerin swabs (irritate eroded tissue and
can decay teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of
magnesia (dries mucosa).
DIF: Cognitive Level: Apply
REF: p. 819
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which expected appearance will the nurse explain to parents of an infant returning from
surgery after an enucleation was performed to treat retinoblastoma? (Select all that apply.)
a. A lot of drainage will come from the affected socket.
b. The face may be edematous or ecchymotic.
c. The eyelids will be sutured shut for the first week.
d. There will be an eye pad dressing taped over the surgical site.
e. The implanted sphere is covered with conjunctiva and resembles the lining of the
mouth.
ANS: B, D, E
After enucleation surgery, the parents are prepared for the child’s facial appearance. An eye
patch is in place, and the child’s face may be edematous or ecchymotic. Parents often fear
seeing the surgical site because they imagine a cavity in the skull. A surgically implanted
sphere maintains the shape of the eyeball, and the implant is covered with conjunctiva. When
the eyelids are open, the exposed area resembles the mucosal lining of the mouth. The
dressing, consisting of an eye pad taped over the surgical site, is changed daily. The wound
itself is clean and has little or no drainage. So expecting a lot of drainage is not accurate to
tell parents. The eyelids are not sutured shut after enucleation surgery.
DIF: Cognitive Level: Apply
REF: p. 839
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The treatment of brain tumors in children consists of which therapies? (Select all that apply.)
a. Surgery
b. Bone marrow transplantation
c. Chemotherapy
d. Stem cell transplantation
e. Radiation
f. Myelography
ANS: A, C, E
Treatment for brain tumors in children may consist of surgery, chemotherapy, and
radiotherapy alone or in combination. Bone marrow and stem cell transplantation therapies
are used for leukemia, lymphoma, and other solid tumors where myeloablative therapies are
used. Myelography is a radiographic examination after an intrathecal injection of contrast
medium. It is not a treatment.
DIF: Cognitive Level: Understand
REF: p. 831
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A clinic nurse is conducting a staff in-service for other clinic nurses about signs and
symptoms of a rhabdomyosarcoma tumor. Which should be included in the teaching session?
(Select all that apply.)
a. Bone fractures
b. Abdominal mass
c. Sore throat and ear pain
d. Headache
e. Ecchymosis of conjunctiva
ANS: B, C, E
The initial signs and symptoms of rhabdomyosarcoma tumors are related to the site of the
tumor and compression of adjacent organs. Some tumor locations, such as the orbit, manifest
early in the course of the illness. Other tumors, such as those of the retroperitoneal area, only
produce symptoms when they are relatively large and compress adjacent organs.
Unfortunately, many of the signs and symptoms attributable to rhabdomyosarcoma are vague
and frequently suggest a common childhood illness, such as “earache” or “runny nose.” An
abdominal mass, sore throat and ear pain, and ecchymosis of conjunctiva are signs of a
rhabdomyosarcoma tumor. Bone fractures would be seen in osteosarcoma, and a headache is
a sign of a brain tumor.
DIF: Cognitive Level: Apply
REF: p. 840
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
SHORT ANSWER
1. A toddler with leukemia is on intravenous chemotherapy treatments. The toddler’s lab results
are WBC: 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. What is this child’s
absolute neutrophil count (ANC)? (Record your answer in a whole number.)
ANS:
140
To calculate an ANC for a WBC = 1000; neutrophils = 7%; and nonsegmented neutrophils
(bands) = 7%, the steps are
Step 1: 7% + 7% = 14%
Step 2: 0.14 ´ 1000 = 140 ANC
DIF: Cognitive Level: Analyze
REF: p. 816
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 26: The Child with Genitourinary Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is conducting a staff in-service on renal ultrasounds. Which statement describes
this diagnostic test?
a. Computed tomography uses external radiation to visualize the renal system.
b. Visualization of the renal system is accomplished without exposure to radiation or
radioactive isotopes.
c. Contrast medium and x-rays allow for visualization of the renal system.
d. External radiation for x-ray films is used to visualize the renal system, before,
during, and after voiding.
ANS: A
A renal ultrasound transmits ultrasonic waves through the renal parenchyma, allowing for
visualization of the renal system without exposure to external beam radiation or radioactive
isotopes. Computed tomography uses external radiation and sometimes contrast media to
visualize the renal system. An intravenous pyelogram uses contrast medium and external
radiation for x-ray films. The voiding cystourethrogram visualizes the renal system with
injection of a contrast media into the bladder through the urethral opening and use of x-ray
before, during, and after voiding.
DIF: Cognitive Level: Understand
REF: p. 848
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is admitting a school-age child in acute renal failure with reduced glomerular
filtration rate. Which urine test is the most useful clinical indication of glomerular filtration
rate?
a. pH
b. Osmolality
c. Creatinine
d. Protein level
ANS: C
The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is
a substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The
pH and osmolality are not estimates of glomerular filtration. Although protein in the urine
demonstrates abnormal glomerular permeability, it is not a measure of filtration rate.
DIF: Cognitive Level: Understand
REF: p. 850
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is conducting an assessment on a school-age child with urosepsis. Which
assessment finding should the nurse expect?
Fever with a positive blood culture
Proteinuria and edema
Oliguria and hypertension
Anemia and thrombocytopenia
a.
b.
c.
d.
ANS: A
Symptoms of urosepsis include a febrile UTI coexisting with systemic signs of bacterial
illness; blood culture reveals presence of urinary pathogen. Proteinuria and edema are
symptoms of minimal change nephrotic syndrome (MCNS). Oliguria and hypertension are
symptoms of acute glomerulonephritis (AGN). Anemia and thrombocytopenia are symptoms
of hemolytic uremic syndrome (HUS).
DIF: Cognitive Level: Analyze
REF: p. 846
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is teaching parents about prevention of urinary tract infections in children. Which
factor predisposes the urinary tract to infection?
Increased fluid intake
Short urethra in young girls
Prostatic secretions in males
Frequent emptying of the bladder
a.
b.
c.
d.
ANS: B
The short urethra in females provides a ready pathway for invasion of organisms. Increased
fluid intake and frequent emptying of the bladder offer protective measures against urinary
tract infections. Prostatic secretions have antibacterial properties that inhibit bacteria.
DIF: Cognitive Level: Understand
REF: p. 846
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. Which should the nurse recommend to prevent urinary tract infections in young girls?
a. Wear cotton underpants.
b. Limit bathing as much as possible.
c. Increase fluids; decrease salt intake.
d. Cleanse perineum with water after voiding.
ANS: A
Cotton underpants are preferable to nylon underpants. No evidence exists that limiting
bathing, increasing fluids/decreasing salt intake, or cleansing the perineum with water after
voiding decrease urinary tract infections in young girls.
DIF: Cognitive Level: Apply
REF: p. 851
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which
finding in this newborn?
Absence of a urethral opening is noted.
Penis appears shorter than usual for age.
The urethral opening is along the dorsal surface of the penis.
The urethral opening is along the ventral surface of the penis.
a.
b.
c.
d.
ANS: D
Hypospadias is a congenital condition in which the urethral opening is located anywhere
along the ventral surface of the penis. The urethral opening is present, but not at the glans.
Hypospadias refers to the urethral opening, not to the size of the penis. A urethral opening
along the ventral surface of the penis is known as epispadias.
DIF: Cognitive Level: Understand
REF: p. 853
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. The nurse is conducting a staff in-service on newborn defects of the genitourinary system.
Which describes the narrowing of the preputial opening of the foreskin?
a. Chordee
b. Phimosis
c. Epispadias
d. Hypospadias
ANS: B
Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the
ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the
penis. Hypospadias is a congenital condition in which the urethral opening is located
anywhere along the ventral surface of the penis.
DIF: Cognitive Level: Remember
REF: p. 853
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which is an objective of care for a 10-year-old child with minimal change nephrotic
syndrome?
a. Reduce blood pressure.
b. Reduce excretion of urinary protein.
c. Increase excretion of urinary protein.
d. Increase ability of tissues to retain fluid.
ANS: B
The objectives of therapy for the child with minimal change nephrotic syndrome include
reduction of the excretion of urinary protein, reduction of fluid retention, prevention of
infection, and minimization of complications associated with therapy. Blood pressure is
usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and
fluid retention are part of the disease process and must be reversed.
DIF: Cognitive Level: Apply
REF: p. 858
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. Which is instituted for the therapeutic management of minimal change nephrotic syndrome?
a. Corticosteroids
b. Antihypertensive agents
c. Long-term diuretics
d. Increased fluids to promote diuresis
ANS: A
Corticosteroids are the first line of therapy for minimal change nephrotic syndrome.
Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic
therapy are usually not necessary. A diet that has fluid and salt restrictions may be indicated.
DIF: Cognitive Level: Apply
REF: p. 858
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
10. Which is a common side effect of short-term corticosteroid therapy?
a. Fever
b. Hypertension
c. Weight loss
d. Increased appetite
ANS: D
Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a
side effect of therapy. It may be an indication of infection. Hypertension is not usually
associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with
corticosteroid therapy.
DIF: Cognitive Level: Understand
REF: p. 860
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
11. The nurse closely monitors the temperature of a child with minimal change nephrotic
syndrome. The purpose of this assessment is to detect an early sign of which possible
complication?
a. Infection
b. Hypertension
c. Encephalopathy
d. Edema
ANS: A
Infection is a constant source of danger to edematous children and those receiving
corticosteroid therapy. An increased temperature could be an indication of an infection.
Temperature is not an indication of hypertension or edema. Encephalopathy is not a
complication usually associated with minimal change nephrotic syndrome. The child will
most likely have neurologic signs and symptoms.
DIF: Cognitive Level: Understand
REF: p. 858
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of
prednisone. Which is an appropriate nursing goal related to this?
Prevent infection
Stimulate appetite
Detect evidence of edema
Ensure compliance with prophylactic antibiotic therapy
a.
b.
c.
d.
ANS: A
High-dose steroid therapy has an immunosuppressant effect. These children are particularly
vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk
of infection by protecting the child from contact with infectious individuals. Appetite is
increased with prednisone therapy. The amount of edema should be monitored as part of the
disease process, not necessarily related to the administration of prednisone. Antibiotics would
not be used as prophylaxis.
DIF: Cognitive Level: Apply
REF: p. 860
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. Which is included in the diet of a child with minimal change nephrotic syndrome?
a. High protein
b. Salt restriction
c. Low fat
d. High carbohydrate
ANS: B
Salt is usually restricted (but not eliminated) during the edema phase. The child has little
appetite during the acute phase. Favorite foods are provided (with the exception of high-salt
ones) in an attempt to provide nutritionally complete meals.
DIF: Cognitive Level: Understand
REF: p. 858
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
14. Which best describes acute glomerulonephritis?
a. Occurs after a urinary tract infection
b. Occurs after a streptococcal infection
c. Associated with renal vascular disorders
d. Associated with structural anomalies of genitourinary tract
ANS: B
Acute glomerulonephritis is an immune-complex disease that occurs after a streptococcal
infection with certain strains of the group A b-hemolytic streptococcus. Acute
glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal
vascular disorders or genitourinary tract structural anomalies.
DIF: Cognitive Level: Understand
REF: p. 860
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. A child is admitted with acute glomerulonephritis. What should the nurse expect the
urinalysis to show during the acute phase?
Bacteriuria, hematuria
Hematuria, proteinuria
Bacteriuria, increased specific gravity
Proteinuria, decreased specific gravity
a.
b.
c.
d.
ANS: B
Urinalysis during the acute phase characteristically shows hematuria and proteinuria.
Bacteriuria and changes in specific gravity are not usually present during the acute phase.
DIF: Cognitive Level: Understand
REF: p. 860
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. A mother asks the nurse what would be the first indication that acute glomerulonephritis is
improving. What is the nurse’s best response?
a. Blood pressure will stabilize.
b. The child will have more energy.
c. Urine will be free of protein.
d. Urinary output will increase.
ANS: D
An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood
pressure is elevated, stabilization usually occurs with the improvement in renal function. The
child having more energy and the urine being free of protein are related to the improvement
in urinary output.
DIF: Cognitive Level: Apply
REF: p. 860
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute
glomerulonephritis. What is most likely the cause of the weight loss?
Poor appetite
Increased potassium intake
Reduction of edema
Restriction to bed rest
a.
b.
c.
d.
ANS: C
This amount of weight loss in this period is a result of the improvement of renal function and
mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8
pounds in 4 days. Foods with substantial amounts of potassium are avoided until renal
function is normalized.
DIF: Cognitive Level: Understand
REF: p. 860
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. The nurse is teaching the parent about the diet of a child experiencing severe edema
associated with acute glomerulonephritis. Which information should the nurse include in the
teaching?
a. “You will need to decrease the number of calories in your child’s diet.”
b. “Your child’s diet will need an increased amount of protein.”
c. “You will need to avoid adding salt to your child’s food.”
d. “Your child’s diet will consist of low-fat, low-carbohydrate foods.”
ANS: C
For most children, a regular diet is allowed, but it should contain no added salt. The child
should be offered a regular diet with favorite foods. Severe sodium restrictions are not
indicated.
DIF: Cognitive Level: Apply
REF: p. 860
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
19. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
a. Risk for Injury related to malignant process and treatment
b. Fluid Volume Deficit related to excessive losses
c. Fluid Volume Excess related to decreased plasma filtration
d. Fluid Volume Excess related to fluid accumulation in tissues and third spaces
ANS: C
Glomerulonephritis has a decreased filtration of plasma, which results in an excessive
accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading
to circulatory congestion and edema. No malignant process is involved in acute
glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to
the decreased plasma filtration.
DIF: Cognitive Level: Analyze
REF: p. 860
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. Which is the most common cause of acute renal failure in children?
a. Pyelonephritis
b. Tubular destruction
c. Urinary tract obstruction
d. Inadequate perfusion
ANS: D
The most common cause of acute renal failure in children is poor perfusion that may respond
to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes
of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the
most common cause.
DIF: Cognitive Level: Understand
REF: p. 862
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse is conducting an admission assessment on a school-age child with acute renal
failure. Which are the primary clinical manifestations the nurse expects to find with this
condition?
a. Oliguria and hypertension
b. Hematuria and pallor
c. Proteinuria and muscle cramps
d. Bacteriuria and facial edema
ANS: A
The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical
manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and
facial edema are not principal features of acute renal failure.
DIF: Cognitive Level: Understand
REF: p. 862
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. The nurse is caring for a child with acute renal failure. Which clinical manifestation should
the nurse recognize as a sign of hyperkalemia?
a. Dyspnea
b. Seizure
c. Oliguria
d. Cardiac arrhythmia
ANS: D
Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia
include electrocardiograph anomalies such as prolonged QRS complex, depressed ST
segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not
manifestations of hyperkalemia.
DIF: Cognitive Level: Apply
REF: p. 862
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. When a child has chronic renal failure, the progressive deterioration produces a variety of
clinical and biochemical disturbances that eventually are manifested in the clinical syndrome
known as:
a. uremia.
b. oliguria.
c. proteinuria.
d. pyelonephritis.
ANS: A
Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is
diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the
urine. Pyelonephritis is an inflammation of the kidney and renal pelvis.
DIF: Cognitive Level: Remember
REF: p. 862
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. Which is a major complication in a child with chronic renal failure?
a. Hypokalemia
b. Metabolic alkalosis
c. Water and sodium retention
d. Excessive excretion of blood urea nitrogen
ANS: C
Chronic renal failure leads to water and sodium retention, which contributes to edema and
vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen
are complications of chronic renal failure.
DIF: Cognitive Level: Understand
REF: p. 866
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. Which clinical manifestation would be seen in a child with chronic renal failure?
a. Hypotension
b. Massive hematuria
c. Hypokalemia
d. Unpleasant “uremic” breath odor
ANS: D
Children with chronic renal failure have a characteristic breath odor resulting from the
retention of waste products. Hypertension may be a complication of chronic renal failure.
With chronic renal failure, little or no urinary output occurs. Hyperkalemia is a concern in
chronic renal failure.
DIF: Cognitive Level: Understand
REF: p. 867
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. One of the clinical manifestations of chronic renal failure is uremic frost. Which best
describes this term?
Deposits of urea crystals in urine
Deposits of urea crystals on skin
Overexcretion of blood urea nitrogen
Inability of body to tolerate cold temperatures
a.
b.
c.
d.
ANS: B
Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the
skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to
elevated levels. There is no relation between cold temperatures and uremic frost.
DIF: Cognitive Level: Understand
REF: p. 867
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. Calcium carbonate is given with meals to a child with chronic renal disease. What is the
purpose of administering calcium carbonate?
Prevent vomiting
Bind phosphorus
Stimulate appetite
Increase absorption of fat-soluble vitamins
a.
b.
c.
d.
ANS: B
Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal
absorption and the serum levels of phosphate. Serum calcium levels are increased by the
calcium carbonate, and vitamin D administration is necessary to increase calcium absorption.
Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption
of fat-soluble vitamins.
DIF: Cognitive Level: Apply
REF: p. 867
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
28. Which should the nurse recommend for the diet of a child with chronic renal failure?
a. High in protein
b. Low in vitamin D
c. Low in phosphorus
d. Supplemented with vitamins A, E, and K
ANS: C
Dietary phosphorus is controlled by the reduction of protein and milk intake to prevent or
control the calcium-phosphorus imbalance. Protein should be limited in chronic renal failure
to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure
to increase calcium absorption. Supplementation of vitamins A, E, and K is not part of dietary
management in chronic renal disease.
DIF: Cognitive Level: Apply
REF: p. 867
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
29. The nurse is caring for an adolescent who has just started dialysis. The child seems always
angry, hostile, or depressed. To what are these behaviors most likely related?
a. Neurologic manifestations that occur with dialysis
b. Physiologic manifestations of renal disease
c. Adolescents having few coping mechanisms
d. Adolescents often resenting the control and enforced dependence imposed by
dialysis
ANS: D
Older children and adolescents need control. The necessity of dialysis forces the adolescent
into a dependent relationship, which results in these behaviors. These are a function of the
child’s age, not neurologic or physiologic manifestations of the dialysis. Feelings of anger,
hostility, and depression are functions of the child’s age, not neurologic or physiologic
manifestations of the dialysis. Adolescents do have coping mechanisms, but they need to
have some control over their disease management.
DIF: Cognitive Level: Analyze
REF: p. 867
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
30. What is an advantage of peritoneal dialysis?
a. Treatments are done in hospitals.
b. Protein loss is less extensive.
c. Dietary limitations are not necessary.
d. Parents and older children can perform treatments.
ANS: D
Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish
to remain independent. Parents and older children can perform the treatments themselves.
Treatments can be done at home. Protein loss is not significantly different. The dietary
limitations are necessary, but they are not as stringent as those for hemodialysis.
DIF: Cognitive Level: Analyze
REF: p. 868
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. Which statement is descriptive of renal transplantation in children?
a. It is an acceptable means of treatment after age 10 years.
b. It is the preferred means of renal replacement therapy in children.
c. Children can receive kidneys only from other children.
d. The decision for transplantation is difficult because a relatively normal lifestyle is
not possible.
ANS: B
Renal transplant offers the opportunity for a relatively normal life and is the preferred means
of renal replacement therapy in end-stage renal disease. Renal transplantation can be done in
children as young as age 6 months. Both children and adults can serve as donors for renal
transplant purposes. Renal transplantation affords the child a more normal lifestyle than
dependence on dialysis.
DIF: Cognitive Level: Understand
REF: p. 868
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. A preschool child is being admitted to the hospital with dehydration and a urinary tract
infection (UTI). Which urinalysis result should the nurse expect with these conditions?
WBC <1; specific gravity 1.008
WBC <2; specific gravity 1.025
WBC >2; specific gravity 1.016
WBC >2; specific gravity 1.030
a.
b.
c.
d.
ANS: D
WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary
tract inflammatory process. The urinalysis specific gravity for children with normal fluid
intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low
specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient
antidiuretic hormone secretion.
DIF: Cognitive Level: Analyze
REF: p. 845
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. The nurse is conducting teaching for an adolescent being discharged to home after a renal
transplant. The adolescent needs further teaching if which statement is made?
a. “I will report any fever to my primary health care provider.”
b. “I am glad I only have to take the immunosuppressant medication for two weeks.”
c. “I will observe my incision for any redness or swelling.”
d. “I won’t miss doing kidney dialysis every week.”
ANS: B
The immunosuppressant medications are taken indefinitely after a renal transplant, so they
should not be discontinued after two weeks. Reporting a fever and observing an incision for
redness and swelling are accurate statements. The adolescent is correct in indicating dialysis
will not need to be done after the transplant.
DIF: Cognitive Level: Apply
REF: p. 860
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
34. The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of
recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement
indicates the parents have understood the teaching?
a. “These injections will help with the hypertension.”
b. “We’re glad the injections only need to be given once a month.”
c. “The red blood cell count should begin to improve with these injections.”
d. “Urine output should begin to improve with these injections.”
ANS: C
Anemia in children with CRF is related to decreased production of erythropoietin.
Recombinant human erythropoietin (rHuEPO) is being offered to these children as thriceweekly or weekly subcutaneous injections and is replacing the need for frequent blood
transfusions. The parents understand the teaching if they say that the red blood cell count will
begin to improve with these injections.
DIF: Cognitive Level: Apply
REF: p. 868
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
35. A school-age child with chronic renal failure is admitted to the hospital with a serum
potassium level of 5.2 mEq/L. Which prescribed medication should the nurse plan to
administer?
a. Spironolactone (Aldactone)
b. Sodium polystyrene sulfonate (Kayexalate)
c. Lactulose (Cephulac)
d. Calcium carbonate (Calcitab)
ANS: B
Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene
sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassiumsparing diuretic and should not be used if the serum potassium is elevated. Lactulose is
administered to reduce ammonia levels in patients with liver disease. Calcium carbonate may
be prescribed as a calcium supplement, but it will not reduce serum potassium levels.
DIF: Cognitive Level: Apply
REF: p. 867
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. The nurse is caring for an infant with a suspected urinary tract infection. Which clinical
manifestations should be expected? (Select all that apply.)
a. Vomiting
b. Jaundice
c. Failure to gain weight
d. Swelling of the face
e. Back pain
f. Persistent diaper rash
ANS: A, C, F
Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations
observed in an infant with a UTI.
DIF: Cognitive Level: Understand
REF: p. 845
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. A school-age child is admitted to the hospital with acute glomerulonephritis and oliguria.
Which dietary menu items should be allowed for this child? (Select all that apply.)
Apples
Bananas
Cheese
Carrot sticks
Strawberries
a.
b.
c.
d.
e.
ANS: A, D, E
Moderate sodium restriction and even fluid restriction may be instituted for children with
acute glomerulonephritis. Foods with substantial amounts of potassium are generally
restricted during the period of oliguria. Apples, carrot sticks, and strawberries would be items
low in sodium and allowed. Bananas are high in potassium, and cheese is high in sodium.
Those items would be restricted.
DIF: Cognitive Level: Apply
REF: p. 849
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A school-age child has been admitted to the hospital with an exacerbation of nephrotic
syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that
apply.)
a. Weight loss
b. Facial edema
c. Cloudy smoky brown-colored urine
d. Fatigue
e. Frothy-appearing urine
ANS: B, D, E
A child with nephrotic syndrome will present with facial edema, fatigue, and frothyappearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention.
Cloudy smoky brown-colored urine is seen with acute glomerulonephritis but not with
nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.
DIF: Cognitive Level: Apply
REF: p. 858
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A 6-year-old child is scheduled for an IV urography (IVP) in the morning. Which preparatory
interventions should the nurse plan to implement? (Select all that apply.)
Clear liquids in the morning before the procedure
Cathartic in the evening before the procedure
Soapsuds enema the morning of the procedure
Insertion of a Foley catheter before the procedure
Teaching with regard to insertion of an intravenous catheter before the procedure
a.
b.
c.
d.
e.
ANS: B, C, E
The IV urography is a test done to provide information about the integrity of the kidneys,
ureters, and bladder. It requires an IV injection of a contrast medium with X-ray films made
5, 10, and 15 minutes after injection. Delayed films (30, 60 minutes, and so on) are also
obtained. The preparation for children ages 2 to 14 years includes cathartic on the evening
before examination, nothing orally after midnight, and an enema (soapsuds) on the morning
of examination. Teaching about the insertion of an intravenous catheter should be part of the
preoperative preparation. Insertion of a Foley catheter is not part of the preparation for an
IVP.
DIF: Cognitive Level: Apply
REF: p. 863
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
SHORT ANSWER
1. The nurse is performing a pH dipstick test on a urine specimen. Which is the average pH
expected for this test? (Record your answer in a whole number.)
ANS:
6
The average pH for urine is 6. The normal range is 4.8 to 7.8. Abnormal pH levels are
associated with urinary infection and metabolic alkalosis or acidosis.
DIF: Cognitive Level: Analyze
REF: p. 850
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 27: The Child with Cerebral Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse has documented that a child’s level of consciousness is obtunded. Which describes
this level of consciousness?
Slow response to vigorous and repeated stimulation
Impaired decision making
Arousable with stimulation
Confusion regarding time and place
a.
b.
c.
d.
ANS: C
Obtunded describes a level of consciousness in which the child is arousable with stimulation.
Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and
repeated stimulation. Confusion is impaired decision making. Disorientation is confusion
regarding time and place.
DIF: Cognitive Level: Understand
REF: p. 874
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse has received report on four children. Which child should the nurse assess first?
a. A school-age child in a coma with stable vital signs
b. A preschool child with a head injury and decreasing level of consciousness
c. An adolescent admitted after a motor vehicle accident is oriented to person and
place
d. A toddler in a persistent vegetative state with a low-grade fever
ANS: B
The nurse should assess the child with a head injury and decreasing level of consciousness
first (LOC). Assessment of LOC remains the earliest indicator of improvement or
deterioration in neurologic status. The next child the nurse should assess is a toddler in a
persistent vegetative state with a low-grade fever. The school-age child in a coma with stable
vital signs and the adolescent admitted to the hospital who is oriented to his surroundings
would be of least worry to the nurse.
DIF: Cognitive Level: Apply
REF: p. 873
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head injury. The
child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place.
Which is the score the nurse should record?
a. 8
b. 11
c. 13
d. 15
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal
response, and motor response. Numeric values of 1 through 5 are assigned to the levels of
response in each category. The sum of these numeric values provides an objective measure of
the patient’s level of consciousness (LOC). A person with an unaltered LOC would score the
highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is
scored at a 15.
DIF: Cognitive Level: Understand
REF: p. 873
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the
child suddenly has a fixed and dilated pupil. How should the nurse interpret these findings?
a. Eye trauma
b. Neurosurgical emergency
c. Severe brainstem damage
d. Indication of brain death
ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The
nurse should immediately report this finding. Although a dilated pupil may be associated with
eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or bilateral fixed
pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and
dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated
pupil is not suggestive of brain death.
DIF: Cognitive Level: Analyze
REF: p. 875
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is caring for a child with severe head trauma after a car accident. Which is an
ominous sign that often precedes death?
Papilledema
Delirium
Doll’s head maneuver
Periodic and irregular breathing
a.
b.
c.
d.
ANS: D
Periodic or irregular breathing is an ominous sign of brainstem (especially medullary)
dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of
optic nerve. It is commonly a sign of increased intracranial pressure Delirium is a state of
mental confusion and excitement marked by disorientation for time and place. The doll’s
head maneuver is a test for brainstem or oculomotor nerve dysfunction.
DIF: Cognitive Level: Understand
REF: p. 880
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is taking care of a child who is alert but showing signs of increased intracranial
pressure. Which test is contraindicated in this case?
Oculovestibular response
Doll’s head maneuver
Funduscopic examination for papilledema
Assessment of pyramidal tract lesions
a.
b.
c.
d.
ANS: A
The oculovestibular response (caloric test) involves the instillation of ice water into the ear of
a comatose child. The caloric test is painful and is never performed on a child who is awake
or one who has a ruptured tympanic membrane. Doll’s head maneuver, funduscopic
examination for papilledema, and assessment of pyramidal tract lesions can be performed on
children who are awake.
DIF: Cognitive Level: Analyze
REF: p. 887
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. The nurse is preparing a school-age child for computed tomography (CT scan) to assess
cerebral function. The nurse should include which statement in preparing the child?
a. “Pain medication will be given.”
b. “The scan will not hurt.”
c. “You will be able to move once the equipment is in place.”
d. “Unfortunately, no one can remain in the room with you during the test.”
ANS: B
For CT scans, the child must be immobilized. It is important to emphasize to the child that at
no time is the procedure painful. Pain medication is not required; however, sedation is
sometimes necessary. Someone is able to remain with the child during the procedure.
DIF: Cognitive Level: Apply
REF: p. 876
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which neurologic diagnostic test gives a visualized horizontal and vertical cross-section of
the brain at any axis?
Nuclear brain scan
Echoencephalography
CT scan
Magnetic resonance imaging (MRI)
a.
b.
c.
d.
ANS: C
A CT scan provides a visualization of the horizontal and vertical cross-sections of the brain at
any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain
barrier is defective. Echoencephalography identifies shifts in midline structures of the brain
as a result of intracranial lesions. MRI permits visualization of morphologic features of target
structures and permits tissue discrimination that is unavailable with any other techniques.
DIF: Cognitive Level: Understand
REF: p. 877
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. Which is the priority nursing intervention for an unconscious child after a fall?
a. Establish adequate airway.
b. Perform neurologic assessment.
c. Monitor intracranial pressure.
d. Determine whether a neck injury is present.
ANS: A
Respiratory effectiveness is the primary concern in the care of the unconscious child.
Establishment of an adequate airway is always the first priority. A neurologic assessment and
determination of whether a neck injury is present will be performed after breathing and
circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after
airway, breathing, and circulation are maintained.
DIF: Cognitive Level: Apply
REF: p. 879
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. Which drug should the nurse expect to administer to a preschool child who has increased
intracranial pressure (ICP) resulting from cerebral edema?
a. Mannitol (Osmitrol)
b. Epinephrine hydrochloride (Adrenalin)
c. Atropine sulfate (Atropine)
d. Sodium bicarbonate (Sodium bicarbonate)
ANS: A
For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used
most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium
bicarbonate are not used to decrease ICP.
DIF: Cognitive Level: Apply
REF: p. 879
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
11. What is an appropriate nursing intervention when caring for an unconscious child?
a. Change the child’s position infrequently to minimize the chance of increased ICP
b. Avoid using narcotics or sedatives to provide comfort and pain relief
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral
edema
d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated
ANS: C
Often comatose patients cannot cope with the quantity of fluids that they normally tolerate.
Overhydration must be avoided to prevent fatal cerebral edema. The child’s position should
be changed frequently to avoid complications such as pneumonia and skin breakdown.
Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which
can increase ICP. Antipyretics are the method of choice for fever reduction.
DIF: Cognitive Level: Apply
REF: p. 879
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. The nurse is planning care for an 8-year-old child with a concussion. Which is descriptive of
a concussion?
a. Petechial hemorrhages cause amnesia.
b. Visible bruising and tearing of cerebral tissue occur.
c. It is a transient and reversible neuronal dysfunction.
d. A slight lesion develops remotely from the site of trauma.
ANS: C
A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of
awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages
along the superficial aspects of the brain along the point of impact are a type of contusion, but
are not necessarily associated with amnesia. A contusion is visible bruising and tearing of
cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result
of an acceleration-deceleration injury.
DIF: Cognitive Level: Understand
REF: p. 883
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is teaching nursing students about childhood fractures. Which describes a
compound skull fracture?
Involves the basilar portion of the occipital bone
Bone is exposed through the skin
Traumatic separations of the cranial sutures
Bone is pushed inward, causing pressure on the brain
a.
b.
c.
d.
ANS: B
A compound fracture has the bone exposed through the skin. A basilar fracture involves the
basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. Diastatic skull
fractures are traumatic separations of the cranial sutures. A depressed fracture has the bone
pushed inward, causing pressure on the brain.
DIF: Cognitive Level: Understand
REF: p. 883
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. Which statement best describes a subdural hematoma?
a. Bleeding occurs between the dura and the skull.
b. Bleeding occurs between the dura and the cerebrum.
c. Bleeding is generally arterial, and brain compression occurs rapidly.
d. The hematoma commonly occurs in the parietotemporal region.
ANS: B
A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of
a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs
between the dura and the skull, is usually arterial with rapid brain concussion, and occurs
most often in the parietotemporal region.
DIF: Cognitive Level: Understand
REF: p. 883
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. When should the nurse recommend medical attention for a child with a slight head injury?
a. Experiences sleepiness
b. Vomits
c. Has a headache
d. Is confused or has abnormal behavior
ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses
consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred
vision, or has an unsteady gait. Sleepiness alone does not require evaluation. If the child is
difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three
times requires medical attention. Severe or worsening headache or one that interferes with
sleep should be evaluated.
DIF: Cognitive Level: Apply
REF: p. 883
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. A 10-year-old boy on a bicycle has been hit by a car in front of the school. The school nurse
immediately assesses airway, breathing, and circulation. What is the next nursing action?
a. Place on side
b. Take blood pressure
c. Stabilize neck and spine
d. Check scalp and back for bleeding
ANS: C
After determining that the child is breathing and has adequate circulation, the next action is to
stabilize the neck and spine to prevent any additional trauma. The child’s position should not
be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less
urgent, but an important assessment, is inspection of the scalp for bleeding.
DIF: Cognitive Level: Apply
REF: p. 886
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. An adolescent boy is brought to the emergency department after a motorcycle accident. His
respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure.
Pupils are dilated and fixed. The nurse should suspect which type of head injury?
a. Brainstem
b. Skull fracture
c. Subdural hemorrhage
d. Epidural hemorrhage
ANS: A
Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping
respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or
extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture,
subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries.
DIF: Cognitive Level: Understand
REF: p. 887
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. A child is unconscious after a motor vehicle accident. The watery discharge from the nose
tests positive for glucose. What does this finding suggest?
Diabetic coma
Brainstem injury
Upper respiratory tract infection
Leaking of cerebrospinal fluid (CSF)
a.
b.
c.
d.
ANS: D
Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a
skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is
probably CSF from a skull fracture and does not signify whether the brainstem is involved.
DIF: Cognitive Level: Apply
REF: p. 906
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
19. A toddler fell out of a second-story window. She had a brief loss of consciousness and
vomited four times. Since admission, she has been alert and oriented. Her mother asks why a
computed tomography (CT) scan is required when she “seems fine.” Which explanation
should the nurse give?
a. Your child may have a brain injury and the CT can rule one out.
b. The CT needs to be done because of your child’s age.
c. Your child may start to have seizures and a baseline CT should be done.
d. Your child probably has a skull fracture and the CT can confirm this diagnosis.
ANS: A
The child’s history of the fall, brief loss of consciousness, and vomiting four times
necessitates evaluation of a potential brain injury. The severity of a head injury may not be
apparent on clinical examination but will be detectable on a CT scan. The need for the CT
scan is related to the injury and symptoms, not the child’s age. The CT scan is necessary to
determine whether a brain injury has occurred.
DIF: Cognitive Level: Apply
REF: p. 876
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. The nurse is assessing a child who was just admitted to the hospital for observation after a
head injury. Which is the most essential part of the nursing assessment to detect early signs of
a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
ANS: D
The most important nursing observation is assessment of the child’s level of consciousness.
Alterations in consciousness appear earlier in the progression of an injury than do alterations
of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic
damage. Vital signs and focal neurologic signs are later signs of progression when compared
with level-of-consciousness changes.
DIF: Cognitive Level: Analyze
REF: p. 886
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. A school-age child has sustained a head injury and multiple fractures after being thrown from
a horse. The child’s level of consciousness is variable. The parents tell the nurse that they
think their child is in pain because of periodic crying and restlessness. What is the most
appropriate nursing action?
a. Discuss with parents the child’s previous experiences with pain
b. Discuss with practitioner what analgesia can be safely administered
c. Explain that analgesia is contraindicated with a head injury
d. Explain that analgesia is unnecessary when child is not fully awake and alert
ANS: B
A key nursing role is to provide sedation and analgesia for the child. Consultation with the
appropriate practitioner is necessary to avoid conflict between the necessity to monitor the
child’s neurologic status and the promotion of comfort and relief of anxiety. Information on
the child’s previous experiences with pain should be obtained as part of the assessment, but
because of the severity of injury, analgesia should be provided as soon as possible. Analgesia
can be safely used in individuals who have sustained head injuries and can decrease anxiety
and resultant increased ICP.
DIF: Cognitive Level: Apply
REF: p. 905
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
22. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for
discharge, the nurse is discussing home care with her mother. Which statement made by the
mother indicates a correct understanding of the teaching?
a. “I should expect my child to have a few episodes of vomiting.”
b. “If I notice sleep disturbances, I should contact the physician immediately.”
c. “I should expect my child to have some behavioral changes after the accident.”
d. “If I notice diplopia, I will have my child rest for 1 hour.”
ANS: C
The parents are advised of probable posttraumatic symptoms that may be expected. These
include behavioral changes and sleep disturbances. If the child has these clinical signs, they
should be immediately reported for evaluation. Sleep disturbances are to be expected.
DIF: Cognitive Level: Apply
REF: p. 883
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. A 3-year-old child is hospitalized after a submersion injury. The child’s mother complains to
the nurse, “Being at the hospital seems unnecessary when he is perfectly fine.” What is the
nurse’s best reply?
a. “He still needs a little extra oxygen.”
b. “I’m sure he is fine, but the doctor wants to make sure.”
c. “The reason for this is that complications could still occur.”
d. “It is important to observe for possible central nervous system problems.”
ANS: C
All children who have a submersion injury should be admitted to the hospital for observation.
Although many children do not appear to have suffered adverse effects from the event,
complications such as respiratory compromise and cerebral edema may occur 24 hours after
the incident. The mother would not think the child is fine if oxygen were still required. The
nurse should clarify that different complications can occur up to 24 hours later and that
observations are necessary.
DIF: Cognitive Level: Apply
REF: p. 888
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The mother of a 1-month-old infant tells the nurse she worries that her baby will get
meningitis like her oldest son did when he was an infant. The nurse should base her response
on which statement?
a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.
d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased
the frequency of this disease in children.
ANS: D
H. influenzae type B meningitis has been virtually eradicated in areas of the world where the
vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It
is significant because of the residual damage caused by undiagnosed and untreated or
inadequately treated cases. The leading causes of neonatal meningitis are the group B
streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of
bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of
the potential causative organisms.
DIF: Cognitive Level: Apply
REF: p. 890
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
25. What are the vector reservoirs for agents causing viral encephalitis in the United States?
a. Tarantula spiders
b. Mosquitoes
c. Carnivorous wild animals
d. Domestic and wild animals
ANS: B
Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by
mosquitoes. The vector reservoir for most agents pathogenic for humans and detected in the
United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during
the hot summer months. Tarantula spiders, carnivorous wild animals, and domestic and wild
animals are not reservoirs for the agents that cause viral encephalitis.
DIF: Cognitive Level: Understand
REF: p. 890
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. What is beneficial in reducing the risk of Reye syndrome?
a. Immunization against the disease
b. Medical attention for all head injuries
c. Prompt treatment of bacterial meningitis
d. Avoidance of aspirin to treat fever associated with influenza
ANS: D
Although the etiology of Reye syndrome is obscure, most cases follow a common viral
illness, either varicella or influenza. A potential association exists between aspirin therapy
and the development of Reye syndrome, so use of aspirin is avoided. No immunization
currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or
bacterial meningitis.
DIF: Cognitive Level: Understand
REF: p. 895
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. When taking the history of a child hospitalized with Reye syndrome, the nurse should not be
surprised that a week ago the child had recovered from:
a.
b.
c.
d.
measles.
varicella.
meningitis.
hepatitis.
ANS: B
Most cases of Reye syndrome follow a common viral illness such as varicella or influenza.
Measles, meningitis, and hepatitis are not associated with Reye syndrome.
DIF: Cognitive Level: Understand
REF: p. 895
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. When caring for the child with Reye syndrome, what is the priority nursing intervention?
a. Monitor intake and output
b. Prevent skin breakdown
c. Observe for petechiae
d. Do range-of-motion exercises
ANS: A
Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes
to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for
petechiae, and doing range-of-motion exercises are important interventions in the care of a
critically ill or comatose child. Careful monitoring of intake and output is a priority.
DIF: Cognitive Level: Apply
REF: p. 895
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
29. A young child’s parents call the nurse after their child was bitten by a raccoon in the woods.
The nurse’s recommendation should be based on which statement?
a. The child should be hospitalized for close observation.
b. No treatment is necessary if thorough wound cleaning is done.
c. Antirabies prophylaxis must be initiated.
d. Antirabies prophylaxis must be initiated if clinical manifestations appear.
ANS: C
Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and
passive immunization with human rabies immune globulin (HRIG) as soon as possible.
Hospitalization is not necessary. The wound cleansing, passive immunization, and immune
globulin administration can be done as an outpatient. The child needs to receive both HRIG
and rabies vaccine.
DIF: Cognitive Level: Apply
REF: p. 895
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. A child is brought to the emergency department after experiencing a seizure at school. There
is no previous history of seizures. The father tells the nurse that he cannot believe the child
has epilepsy. What is the nurse’s best response?
a.
b.
c.
d.
“Epilepsy is easily treated.”
“Very few children have actual epilepsy.”
“The seizure may or may not mean that your child has epilepsy.”
“Your child has had only one convulsion; it probably won’t happen again.”
ANS: C
Seizures are the indispensable characteristic of epilepsy; however, not every seizure is
epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The
treatment of epilepsy involves a thorough assessment to determine the type of seizure the
child is having and the cause, followed by individualized therapy to allow the child to have as
normal a life as possible. The nurse should not make generalized comments regarding the
incidence of epilepsy until further assessment is made.
DIF: Cognitive Level: Apply
REF: p. 896
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. Which type of seizure involves both hemispheres of the brain?
a. Focal
b. Partial
c. Generalized
d. Acquired
ANS: C
Clinical observations of generalized seizures indicate that the initial involvement is from both
hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal,
temporal, and parietal lobes are most commonly affected. Partial seizures are caused by
abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the
cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety
of factors; it does not specify the type of seizure.
DIF: Cognitive Level: Remember
REF: p. 896
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. Which is the initial clinical manifestation of generalized seizures?
a. Being confused
b. Feeling frightened
c. Losing consciousness
d. Seeing flashing lights
ANS: C
Loss of consciousness is a frequent occurrence in generalized seizures and is the initial
clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are
clinical manifestations of a complex partial seizure.
DIF: Cognitive Level: Understand
REF: p. 896
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. Which of the following types of seizures may be difficult to detect?
a. Absence
b. Generalized
c. Simple partial
d. Complex partial
ANS: A
Absence seizures may go unrecognized because little change occurs in the child’s behavior
during the seizure. Generalized, simple partial, and complex partial seizures all have clinical
manifestations that are observable.
DIF: Cognitive Level: Understand
REF: p. 896
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. What is an important nursing intervention when caring for a child who is experiencing a
seizure?
Describe and record the seizure activity observed.
Restrain the child when seizure occurs to prevent bodily harm.
Place a tongue blade between the teeth if they become clenched.
Suction the child during a seizure to prevent aspiration.
a.
b.
c.
d.
ANS: A
When a child is having a seizure, the priority nursing care is observation of the child and
seizure. The nurse then describes and records the seizure activity. The child should not be
restrained, and nothing should be placed in the child’s mouth. This may cause injury. To
prevent aspiration, if possible, the child should be placed on the side, facilitating drainage.
DIF: Cognitive Level: Apply
REF: p. 896
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
35. A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure
at school. Breathing is not impaired, but some postictal confusion occurs. What is the most
appropriate initial action by the school nurse?
a. Stay with child and have someone call emergency medical service (EMS)
b. Notify parent and regular practitioner
c. Notify parent that child should go home
d. Stay with child, offering calm reassurance
ANS: A
The EMS should be called to transport the child because this is the child’s first seizure.
Because this is the first seizure, evaluation should be performed as soon as possible. The
nurse should stay with the child while someone else notifies the EMS.
DIF: Cognitive Level: Apply
REF: p. 897
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
36. A child has been seizure-free for 2 years. A father asks the nurse how much longer the child
will need to take the antiseizure medications. The nurse includes which intervention in the
response?
a. Medications can be discontinued at this time.
b. The child will need to take the drugs for 5 years after the last seizure.
c. A step-wise approach will be used to reduce the dosage gradually.
d. Seizure disorders are a lifelong problem. Medications cannot be discontinued.
ANS: C
A predesigned protocol is used to wean a child gradually off antiseizure medications, usually
when the child is seizure-free for 2 years and has a normal electroencephalogram (EEG).
Medications must be gradually reduced to minimize the recurrence of seizures. Seizure
medications can be safely discontinued. The risk of recurrence is greatest within the first year.
DIF: Cognitive Level: Apply
REF: p. 899
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
37. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin (Dilantin) may
experience a deficiency of:
calcium.
vitamin C.
fat-soluble vitamins.
vitamin D and folic acid.
a.
b.
c.
d.
ANS: D
Deficiencies of vitamin D and folic acid have been reported in children taking phenobarbital
and phenytoin. Calcium, vitamin C, and fat-soluble vitamin deficiencies are not associated
with phenobarbital or phenytoin.
DIF: Cognitive Level: Understand
REF: p. 905
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
38. Which clinical manifestations would suggest hydrocephalus in a neonate?
a. Bulging fontanel and dilated scalp veins
b. Closed fontanel and high-pitched cry
c. Constant low-pitched cry and restlessness
d. Depressed fontanel and decreased blood pressure
ANS: A
Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of
hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry
and restlessness, and depressed fontanel and decreased blood pressure are not clinical
manifestations of hydrocephalus, but all should be referred for evaluation.
DIF: Cognitive Level: Analyze
REF: p. 906
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. Which are clinical manifestations of increased intracranial pressure (ICP) in infants? (Select
all that apply.)
Low-pitched cry
Sunken fontanel
Diplopia and blurred vision
Irritability
Distended scalp veins
Increased blood pressure
a.
b.
c.
d.
e.
f.
ANS: D, E
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP
in infants. Diplopia and blurred vision are indicative of elevated ICP in children. A highpitched cry and a tense or bulging fontanel are characteristics of increased ICP. Increased
blood pressure, common in adults, is rarely seen in children.
DIF: Cognitive Level: Understand
REF: p. 872
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal
shunt. Which interventions should be included in the child’s postoperative care? (Select all
that apply.)
a. Observe closely for signs of infection.
b. Pump the shunt reservoir to maintain patency.
c. Administer sedation to decrease irritability.
d. Maintain Trendelenburg position to decrease pressure on the shunt.
e. Maintain an accurate record of intake and output.
f. Monitor for abdominal distention.
ANS: A, E, F
Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of
infection is a priority nursing intervention. Intake and output should be measured carefully.
Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping of the
shunt may cause obstruction or other problems and should not be performed unless indicated
by the neurosurgeon. Pain management rather than sedation should be the goal of therapy.
The child is kept flat to avoid too rapid a reduction of intracranial fluid.
DIF: Cognitive Level: Apply
REF: p. 877
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3-year-old
child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that
apply.)
a. Elevated white blood cell (WBC) count
b. Decreased glucose
c. Normal protein
d. Elevated red blood cell (RBC) count
ANS: A, B
The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count,
decreased glucose, and increased protein content. There should not be RBCs evident in the
CSF fluid.
DIF: Cognitive Level: Analyze
REF: p. 890
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations
should the nurse prepare to assess if meningitis is confirmed? (Select all that apply.)
a. Headache
b. Photophobia
c. Bulging anterior fontanel
d. Weak cry
e. Poor muscle tone
ANS: C, D, E
Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry,
and poor muscle tone. Headache and photophobia are signs seen in an older child.
DIF: Cognitive Level: Understand
REF: p. 890
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which
are late signs of increased intracranial pressure (ICP) in an infant? (Select all that apply.)
Tachycardia
Alteration in pupil size and reactivity
Increased motor response
Extension or flexion posturing
Cheyne-Stokes respirations
a.
b.
c.
d.
e.
ANS: B, D, E
Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and
reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes
respirations.
DIF: Cognitive Level: Analyze
REF: p. 872
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
OTHER
1. A 6-year-old child is having a generalized seizure in the classroom at school. Place in order
the interventions the school nurse should implement starting with the highest-priority
intervention sequencing to the lowest-priority intervention. Provide the answer using
lowercase letters separated by commas (e.g., a, b, c, d, e).
a. Take vital signs.
b. Ease child to the floor.
c. Allow child to rest.
d. Turn child to the side.
e. Integrate child back into the school environment.
ANS:
b, d, a, c, e
The nurse should ease the child to the floor immediately during a generalized seizure. During
(and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation
increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway
occlusion. Placing the child on the side facilitates drainage and helps maintain a patent
airway. Vital signs should be taken next and the child should be allowed to rest. When
feasible, the child is integrated into the environment as soon as possible.
DIF: Cognitive Level: Apply
REF: p. 881
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 28: The Child with Endocrine Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Parents of a toddler with hypopituitarism ask the nurse, “What can we expect with this
condition?” The nurse should respond with which statement?
Growth is normal during the first 3 years of life.
Weight is usually more retarded than height.
Skeletal proportions are normal for age.
Most of these children have subnormal intelligence.
a.
b.
c.
d.
ANS: C
In children with hypopituitarism, the skeletal proportions are normal. Growth is within
normal limits for the first year of life. Height is usually more delayed than weight.
Intelligence is not affected by hypopituitarism.
DIF: Cognitive Level: Apply
REF: p. 911
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing
considerations should be based on which knowledge?
a. Treatment is most successful if it is started during adolescence.
b. Treatment is considered successful if children attain full stature by adulthood.
c. Replacement therapy requires daily subcutaneous injections.
d. Replacement therapy will be required throughout the child’s lifetime.
ANS: C
Additional support is required for children who require hormone replacement therapy, such as
preparation for daily subcutaneous injections and education for self-management during the
school-age years. Young children, obese children, and those who are severely GH deficient
have the best response to therapy. When therapy is successful, children can attain their actual
or near-final adult height at a slower rate than their peers. Replacement therapy is not needed
after attaining final height. They are no longer GH deficient.
DIF: Cognitive Level: Analyze
REF: p. 911
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
3. A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time
for the GH to be administered?
At bedtime
After meals
Before meals
On arising in the morning
a.
b.
c.
d.
ANS: A
Injections are best given at bedtime to more closely approximate the physiologic release of
GH. After or before meals and on arising in the morning do not mimic the physiologic release
of the hormone.
DIF: Cognitive Level: Apply
REF: p. 911
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
4. An adolescent is being seen in the clinic for evaluation of acromegaly. The nurse understands
that which occurs with acromegaly?
a. There is a lack of growth hormone (GH) being produced.
b. There is excess growth hormone (GH) after closure of the epiphyseal plates.
c. There is an excess of growth hormone (GH) before the closure of the epiphyseal
plates.
d. There is a lack of thyroid hormone being produced.
ANS: B
Excess GH after closure of the epiphyseal plates results in acromegaly. A lack of growth
hormone results in delayed growth or even dwarfism. Gigantism occurs when there is
hypersecretion of GH before the closure of the epiphyseal plates. Cretinism is associated with
hypothyroidism.
DIF: Cognitive Level: Understand
REF: p. 912
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. A child will start treatment for precocious puberty. The nurse recognizes that this will involve
the injection of which synthetic medication?
Thyrotropin
Gonadotropins
Somatotropic hormone
Luteinizing hormone–releasing hormone
a.
b.
c.
d.
ANS: D
Precocious puberty of central origin is treated with monthly subcutaneous injections of
luteinizing hormone–releasing hormone. Thyrotropin, gonadotropins, and somatotropic
hormone are not the appropriate therapies for precocious puberty.
DIF: Cognitive Level: Understand
REF: p. 912
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
6. The nurse is conducting a staff in-service on childhood endocrine disorders. Diabetes
insipidus is a disorder of:
anterior pituitary.
posterior pituitary.
adrenal cortex.
adrenal medulla.
a.
b.
c.
d.
ANS: B
The principal disorder of posterior pituitary hypofunction is diabetes insipidus. The anterior
pituitary produces hormones such as GH, thyroid-stimulating hormone, adrenocorticotropic
hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The adrenal cortex
produces aldosterone, sex hormones, and glucocorticoids. The adrenal medulla produces
catecholamines.
DIF: Cognitive Level: Understand
REF: p. 912
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. The nurse is caring for a preschool child with suspected diabetes insipidus. Which clinical
manifestation should the nurse expect to observe?
Oliguria
Glycosuria
Nausea and vomiting
Polyuria and polydipsia
a.
b.
c.
d.
ANS: D
Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of
diabetes. These symptoms may be so severe that the child does little other than drink and
urinate. Oliguria is decreased urine production and is not associated with diabetes insipidus.
Glycosuria is associated with diabetes mellitus. Nausea and vomiting are associated with
inappropriate antidiuretic hormone (ADH) secretion.
DIF: Cognitive Level: Apply
REF: p. 917
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. A nasal spray of desmopressin acetate (DDAVP) is used to treat which disorder?
a. Hypopituitarism
b. Diabetes insipidus
c. Acute adrenocortical insufficiency
d. Syndrome of inappropriate antidiuretic hormone
ANS: B
The drug of choice for the treatment of diabetes insipidus is DDAVP, which is a synthetic
analogue of vasopressin. DDAVP is not used to treat hypopituitarism, acute adrenocortical
insufficiency, or syndrome of inappropriate antidiuretic hormone.
DIF: Cognitive Level: Understand
REF: p. 917
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
9. The nurse is admitting a toddler with the diagnosis of juvenile hypothyroidism. Which is a
common clinical manifestation of this disorder?
Insomnia
Diarrhea
Dry skin
Accelerated growth
a.
b.
c.
d.
ANS: C
Dry skin, mental decline, and myxedematous skin changes are associated with juvenile
hypothyroidism. Children with hypothyroidism are usually sleepy. Constipation is associated
with hypothyroidism. Decelerated growth is common in juvenile hypothyroidism.
DIF: Cognitive Level: Apply
REF: p. 919
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. A goiter is an enlargement or hypertrophy of which gland?
a. Thyroid
b. Adrenal
c. Anterior pituitary
d. Posterior pituitary
ANS: A
A goiter is an enlargement or hypertrophy of the thyroid gland. Goiter is not associated with
the adrenal, anterior pituitary, or posterior pituitary organs.
DIF: Cognitive Level: Remember
REF: p. 919
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. What condition may cause exophthalmos (protruding eyeballs) in children?
a. Hypothyroidism
b. Hyperthyroidism
c. Hypoparathyroidism
d. Hyperparathyroidism
ANS: B
Exophthalmos is a clinical manifestation of hyperthyroidism. Hypothyroidism,
hypoparathyroidism, and hyperparathyroidism are not associated with exophthalmos.
DIF: Cognitive Level: Understand
REF: p. 920
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. The nurse is teaching the parents of a child who is receiving methimazole (Tapazole) for the
treatment of hyperthyroidism (Graves disease). Which statement made by the parent indicates
a correct understanding of the teaching?
a. “I would expect my child to gain weight while taking this medication.”
b. “I would expect my child to experience episodes of ear pain while taking this
medication.”
c. “If my child develops a sore throat and fever, I should contact the physician
immediately.”
d. “If my child develops the stomach flu, my child will need to be hospitalized.”
ANS: C
Children being treated with Tapazole must be carefully monitored for the side effects of the
medication. Parents must be alerted that sore throat and fever accompany the grave
complication of leukopenia. These symptoms should be immediately reported. Weight gain,
episodes of ear pain, and concern for hospitalization with the stomach flu are not concerns
related to taking Tapazole.
DIF: Cognitive Level: Apply
REF: p. 920
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. Which clinical manifestation may occur in the child who is receiving too much methimazole
(Tapazole) for the treatment of hyperthyroidism (Graves disease)?
a. Seizures
b. Enlargement of all lymph glands
c. Pancreatitis or cholecystitis
d. Lethargy and somnolence
ANS: D
Parents should be aware of the signs of hypothyroidism that can occur from overdosage of
the drug. The most common manifestations are lethargy and somnolence. Seizures and
pancreatitis are not associated with the administration of Tapazole. Enlargement of the
salivary and cervical lymph glands occurs.
DIF: Cognitive Level: Apply
REF: p. 920
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be
advised to watch for which sign of vitamin D toxicity?
a.
b.
c.
d.
Headache and seizures
Physical restlessness and voracious appetite without weight gain
Weakness and lassitude
Anorexia and insomnia
ANS: C
Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for
signs, including weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal
impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a
sign of vitamin D toxicity, but seizures are not. Physical restlessness and a voracious appetite
with weight loss are manifestations of hyperthyroidism. Anorexia and insomnia are not
characteristic of vitamin D toxicity.
DIF: Cognitive Level: Apply
REF: p. 921
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. What secretes glucocorticoids, mineralocorticoids, and sex steroids?
a. Thyroid gland
b. Parathyroid glands
c. Adrenal cortex
d. Anterior pituitary
ANS: C
These hormones are secreted by the adrenal cortex. The thyroid gland produces thyroid
hormone and thyrocalcitonin. The parathyroid gland produces parathyroid hormone. The
anterior pituitary produces hormones such as GH, thyroid-stimulating hormone,
adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone.
DIF: Cognitive Level: Understand
REF: p. 923
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. What is chronic adrenocortical insufficiency also called?
a. Graves disease
b. Addison disease
c. Cushing syndrome
d. Hashimoto disease
ANS: B
Addison disease is chronic adrenocortical insufficiency. Graves and Hashimoto diseases
involve the thyroid gland. Cushing syndrome is a result of excessive circulation of free
cortisol.
DIF: Cognitive Level: Remember
REF: p. 924
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital
hyperplasia. What does therapeutic management include?
a.
b.
c.
d.
Administration of vitamin D
Administration of cortisone
Administration of stool softeners
Administration of calcium carbonate
ANS: B
Cortisone is administered to suppress the abnormally high secretions of adrenocorticotropic
hormone (ACTH). This in turn inhibits the secretion of adrenocorticosteroid, which stems the
progressive virilization. Vitamin D, stool softeners, and calcium carbonate have no role in the
therapy of adrenogenital hyperplasia.
DIF: Cognitive Level: Understand
REF: p. 923
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
18. The parents of a neonate with adrenogenital hyperplasia tell the nurse that they are afraid to
have any more children. The nurse should explain which statement about adrenogenital
hyperplasia?
a. It is not hereditary.
b. Genetic counseling is indicated.
c. It can be prevented during pregnancy.
d. All future children will have the disorder.
ANS: B
Some forms of adrenogenital hyperplasia are hereditary and should be referred for genetic
counseling. Affected offspring should also be referred for genetic counseling. There is an
autosomal recessive form of adrenogenital hyperplasia. A prenatal treatment with
glucocorticoids can be offered to the mother during pregnancy to avoid the sex ambiguity, but
it does not affect the presence of the disease. If it is the heritable form, for each pregnancy, a
25% risk occurs that the child will be affected.
DIF: Cognitive Level: Apply
REF: p. 923
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
19. Which is characteristic of the immune-mediated type 1 diabetes mellitus?
a. Ketoacidosis is infrequent.
b. Onset is gradual.
c. Age at onset is usually younger than 20 years.
d. Oral agents are often effective for treatment.
ANS: C
The immune-mediated type 1 diabetes mellitus typically has its onset in children or young
adults. Infrequent ketoacidosis, gradual onset, and effectiveness of oral agents for treatment
are more consistent with type 2 diabetes.
DIF: Cognitive Level: Analyze
REF: p. 931
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. Which is considered a cardinal sign of diabetes mellitus?
a. Nausea
b. Seizures
c. Impaired vision
d. Frequent urination
ANS: D
Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures
are not clinical manifestations of diabetes mellitus. Impaired vision is a long-term
complication of the disease.
DIF: Cognitive Level: Understand
REF: p. 936
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. Hyperglycemia associated with diabetic ketoacidosis is defined as a blood glucose
measurement equal to or greater than _____ mg/dl.
100
120
180
200
a.
b.
c.
d.
ANS: D
Diabetic ketoacidosis is a state of relative insulin insufficiency and may include the presence
of hyperglycemia, a blood glucose level greater than or equal to 200 mg/dl. The values 100
mg/dl, 120 mg/dl, and 180 mg/dl are too low for the definition of ketoacidosis.
DIF: Cognitive Level: Understand
REF: p. 940
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be
present?
Moist skin
Weight gain
Fluid overload
Poor wound healing
a.
b.
c.
d.
ANS: D
Poor wound healing may be present in an individual with type 1 diabetes mellitus. Dry skin,
weight loss, and dehydration are clinical manifestations of type 1 diabetes mellitus.
DIF: Cognitive Level: Understand
REF: p. 928
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. A parent asks the nurse why self-monitoring of blood glucose is being recommended for her
child with diabetes. The nurse should base the explanation on which knowledge?
a. It is a less expensive method of testing.
b. It is not as accurate as laboratory testing.
c. Children are better able to manage the diabetes.
d. Parents are better able to manage the disease.
ANS: C
Blood glucose self-management has improved diabetes management and can be used
successfully by children from the time of diagnosis. Insulin dosages can be adjusted based on
blood glucose results. Blood glucose monitoring is more expensive but provides improved
management. It is as accurate as equivalent testing done in laboratories. The ability to selftest allows the child to balance diet, exercise, and insulin. The parents are partners in the
process, but the child should be taught how to manage the disease.
DIF: Cognitive Level: Apply
REF: p. 928
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The parent of a child with diabetes mellitus asks the nurse when urine testing will be
necessary. The nurse should explain that urine testing is necessary for which?
Glucose is needed before administration of insulin.
Glucose is needed four times a day.
Glycosylated hemoglobin is required.
Ketonuria is suspected.
a.
b.
c.
d.
ANS: D
Urine testing is still performed to detect evidence of ketonuria. Urine testing for glucose is no
longer indicated because of the poor correlation between blood glucose levels and glycosuria.
Glycosylated hemoglobin analysis is performed on a blood sample.
DIF: Cognitive Level: Apply
REF: p. 929
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise.
Which should the nurse explain about exercise in type 1 diabetes?
Exercise will increase blood glucose.
Exercise should be restricted.
Extra snacks are needed before exercise.
Extra insulin is required during exercise.
a.
b.
c.
d.
ANS: C
Exercise lowers blood glucose levels, which can be compensated for by extra snacks.
Exercise lowers blood glucose and is encouraged and not restricted, unless indicated by other
health conditions. Extra insulin is contraindicated because exercise decreases blood glucose
levels.
DIF: Cognitive Level: Apply
REF: p. 929
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. A child eats some sugar cubes after experiencing symptoms of hypoglycemia. What should
follow this rapid-releasing sugar?
a. Fat
b. Fruit juice
c. Several glasses of water
d. Complex carbohydrate and protein
ANS: D
Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a
complex carbohydrate and protein. Fat, fruit juice, and several glasses of water do not
provide the child with complex carbohydrate and protein necessary to stabilize the blood
glucose.
DIF: Cognitive Level: Apply
REF: p. 930
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. The nurse is caring for an 8-year-old child with type 1 diabetes. The nurse should teach the
child to monitor for which manifestation of hypoglycemia?
Lethargy
Thirst
Nausea and vomiting
Shaky feeling and dizziness
a.
b.
c.
d.
ANS: D
Some of the clinical manifestations of hypoglycemia include shaky feelings; dizziness;
difficulty concentrating, speaking, focusing, or coordinating; sweating; and pallor. Lethargy,
thirst, and nausea and vomiting are manifestations of hyperglycemia.
DIF: Cognitive Level: Apply
REF: p. 931
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. The nurse is caring for an 11-year-old boy who has recently been diagnosed with diabetes.
Which should be included in the teaching plan for daily injections?
a. The parents do not need to learn the procedure.
b. He is old enough to give most of his own injections.
c. Self-injections will be possible when he is closer to adolescence.
d. He can learn about self-injections when he is able to reach all injection sites.
ANS: B
School-age children are able to give their own injections. Parents should participate in
learning and giving the insulin injections. He is already old enough to administer his own
insulin. The child is able to use thighs, abdomen, part of the hip, and arm. Assistance can be
obtained if other sites are used.
DIF: Cognitive Level: Apply
REF: p. 931
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29. The nurse is discussing with a child and family the various sites used for insulin injections.
Which site usually has the fastest rate of absorption?
a. Arm
b. Leg
c. Buttock
d. Abdomen
ANS: D
The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast
rate of absorption but short duration. The leg has a slow rate of absorption but a long
duration. The buttock has the slowest rate of absorption and the longest duration.
DIF: Cognitive Level: Apply
REF: p. 931
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
30. To help the adolescent deal with diabetes, the nurse must consider which characteristic of
adolescence?
Desire to be unique
Preoccupation with the future
Need to be perfect and similar to peers
Need to make peers aware of the seriousness of hypoglycemic reactions
a.
b.
c.
d.
ANS: C
Adolescence is a time when the individual wants to be perfect and similar to peers. Having
diabetes makes adolescents different from their peers. Adolescents do not wish to be unique;
they desire to fit in with the peer group and are usually not future oriented. Forcing peer
awareness of the seriousness of hypoglycemic reactions would further alienate the adolescent
with diabetes. The peer group would focus on the differences.
DIF: Cognitive Level: Analyze
REF: p. 940
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
31. The nurse is implementing care for a school-age child admitted to the pediatric intensive care
in diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement
first?
a. Begin 0.9% saline solution intravenously as prescribed.
b. Administer regular insulin intravenously as prescribed.
c. Place child on a cardiac monitor.
d. Place child on a pulse oximetry monitor.
ANS: A
All patients with DKA experience dehydration (10% of total body weight in severe
ketoacidosis) because of the osmotic diuresis, accompanied by depletion of electrolytes,
sodium, potassium, chloride, phosphate, and magnesium. The initial hydrating solution is
0.9% saline solution. Insulin therapy should be started after the initial rehydration bolus
because serum glucose levels fall rapidly after volume expansion. The child should be placed
on the cardiac and pulse oximetry monitor after the rehydrating solution has been initiated.
DIF: Cognitive Level: Analyze
REF: p. 933
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. The nurse should teach parents of a preschool child with type 1 diabetes that which can raise
the blood glucose level?
a. Exercise
b. Steroids
c. Decreased food intake
d. Lantus insulin
ANS: B
Parents should understand how to adjust food, activity, and insulin at the time of illness or
when the child is treated for an illness with a medication known to raise the blood glucose
level (e.g., steroids). Exercise, insulin, and decreased food intake can cause hypoglycemia.
DIF: Cognitive Level: Apply
REF: p. 939
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
33. A nurse is reviewing the laboratory results on a school-age child with hypoparathyroidism.
Which results are consistent with this condition?
Decreased serum phosphorus
Decreased serum calcium
Increased serum glucose
Decreased serum cortisol level
a.
b.
c.
d.
ANS: B
The diagnosis of hypoparathyroidism is made on the basis of clinical manifestations
associated with decreased serum calcium and increased serum phosphorus. A decreased
serum phosphorus level would be seen in hyperparathyroidism, elevated glucose in diabetes,
and a decreased serum cortisol level in adrenocortical insufficiency (Addison disease).
DIF: Cognitive Level: Analyze
REF: p. 921
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. Nursing care of a child diagnosed with a syndrome of inappropriate ADH should include
which of the following? (Select all that apply.)
a. Weigh daily
b. Encourage fluids
c. Turn frequently
d. Maintain nothing by mouth (NPO)
e. Restrict fluids
ANS: A, E
Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid
volume and decreases serum osmolarity with a progressive reduction in sodium
concentration. The immediate management of the child is to restrict fluids. The child should
also be weighed at the same time each day. Encouraging fluids will worsen the child’s
condition. Turning frequently is not an appropriate intervention unless the child is
unresponsive. Fluids, not food, should be restricted.
DIF: Cognitive Level: Analyze
REF: p. 912
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse should expect to assess which clinical manifestations in an adolescent with
Cushing syndrome? (Select all that apply.)
Hyperglycemia
Hyperkalemia
Hypotension
Cushingoid features
Susceptibility to infections
a.
b.
c.
d.
e.
ANS: A, D, E
In Cushing syndrome, physiologic disturbances seen are Cushingoid features hyperglycemia,
susceptibility to infection, hypertension, and hypokalemia.
DIF: Cognitive Level: Analyze
REF: p. 925
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. A nurse is planning care for a school-age child with type 1 diabetes. Which insulin
preparations are rapid and short acting? (Select all that apply.)
a. Novolin N
b. Lantus
c. NovoLog
d. Novolin R
ANS: C, D
Rapid-acting insulin (e.g., NovoLog) reaches the blood within 15 minutes after injection. The
insulin peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular)
insulin (e.g., Novolin R) usually reaches the blood within 30 minutes after injection. The
insulin peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours. Intermediateacting insulins (e.g., Novolin N) reach the blood 2 to 6 hours after injection. The insulins
peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long-acting insulin
(e.g., Lantus) takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to
16 hours after injection. The insulin stays in the blood between 20 and 24 hours.
DIF: Cognitive Level: Understand
REF: p. 930
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A nurse is planning interventions for a toddler with juvenile hypothyroidism. Which
interventions should the nurse plan to implement for this child? (Select all that apply.)
a.
b.
c.
d.
Moisturizer for dry skin
Antidiarrheal medications
Medications to help with insomnia
Implementation of thyroxine therapy
ANS: A, D
The presenting symptoms of juvenile hypothyroidism are myxedematous skin changes (dry
skin, puffiness around the eyes, sparse hair), constipation, lethargy, and mental decline. The
nurse should plan interventions for the dry skin and for the implementation of thyroxine
therapy. The child is prone to constipation and sleepiness so antidiarrheal medication and
medications to help with insomnia would not be appropriate.
DIF: Cognitive Level: Apply
REF: p. 919
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is caring for a school-age child with hyperthyroidism (Graves disease). Which
clinical manifestations should the nurse monitor that may indicate a thyroid storm? (Select all
that apply.)
a. Constipation
b. Hypotension
c. Hyperthermia
d. Tachycardia
e. Vomiting
ANS: C, D, E
A child with a thyroid storm will have severe irritability and restlessness, vomiting, diarrhea,
hyperthermia, hypertension, severe tachycardia, and prostration.
DIF: Cognitive Level: Understand
REF: p. 920
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
COMPLETION
1. The clinic nurse is reviewing hemoglobin A1c levels on several children with type 1 diabetes.
Hemoglobin A1c levels of less than _____% are a goal for children with type 1 diabetes.
(Record your answer in a whole number.)
ANS:
7
The measurement of glycosylated hemoglobin (hemoglobin A1c) levels is a satisfactory
method for assessing control of the diabetes. As red blood cells circulate in the bloodstream,
glucose molecules gradually attach to the hemoglobin A molecules and remain there for the
lifetime of the red blood cell, approximately 120 days. The attachment is not reversible;
therefore, this glycosylated hemoglobin reflects the average blood glucose levels over the
previous 2 to 3 months. The test is a satisfactory method for assessing control, detecting
incorrect testing, monitoring the effectiveness of changes in treatment, defining patients’
goals, and detecting nonadherence. Hemoglobin A1c levels of less than 7% are a wellestablished goal at most care centers.
DIF: Cognitive Level: Analyze
REF: p. 931
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 29: The Child with Musculoskeletal or Articular Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which
complication should the nurse monitor related to the child’s immobilization status?
a. Metabolic rate increases
b. Increased joint mobility leading to contractures
c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia)
d. Venous stasis leading to thrombi or emboli formation
ANS: D
The physiologic effects of immobilization, as a result of decreased muscle contraction,
include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate
decreases with immobilization. Loss of joint mobility leads to contractures. Bone
demineralization with osteoporosis and hypercalcemia occur with immobilization.
DIF: Cognitive Level: Apply
REF: p. 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is caring for a preschool child immobilized by a spica cast. Which effect on
metabolism should the nurse monitor on this child related to the immobilized status?
Hypocalcemia
Decreased metabolic rate
Positive nitrogen balance
Increased production of stress hormones
a.
b.
c.
d.
ANS: B
Immobilization causes a decreased metabolic rate with slowing of all systems and a
decreased food intake. Immobilization leads to hypercalcemia and causes a negative nitrogen
balance secondary to muscle atrophy. A decreased production of stress hormones occurs with
decreased physical and emotional coping capacity.
DIF: Cognitive Level: Understand
REF: p. 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse should monitor for which effect on the cardiovascular system when a child is
immobilized?
Venous stasis
Increased vasopressor mechanism
Normal distribution of blood volume
Increased efficiency of orthostatic neurovascular reflexes
a.
b.
c.
d.
ANS: A
The physiologic effects of immobilization, as a result of decreased muscle contraction,
include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased
vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased
cerebral blood flow, and tachycardia. An altered distribution of blood volume is found with
decreased cardiac workload and exercise tolerance. Immobilization causes a decreased
efficiency of orthostatic neurovascular reflexes with an inability to adapt readily to the
upright position and with pooling of blood in the extremities in the upright position.
DIF: Cognitive Level: Understand
REF: p. 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. Which can result from the bone demineralization associated with immobility?
a. Osteoporosis
b. Urinary retention
c. Pooling of blood
d. Susceptibility to infection
ANS: A
Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic
fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to
the effect of immobilization on the urinary tract. Pooling of blood is a result of the
cardiovascular effects of immobilization. Susceptibility to infection can result from the
effects of immobilization on the respiratory and renal systems.
DIF: Cognitive Level: Understand
REF: p. 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. A young girl has just injured her ankle at school. In addition to calling the child’s parents,
what is the most appropriate immediate action by the school nurse?
a. Apply ice.
b. Observe for edema and discoloration.
c. Encourage child to assume a position of comfort.
d. Obtain parental permission for administration of acetaminophen or aspirin.
ANS: A
Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be
rested, be elevated, and have compression applied. Observing for edema and discoloration,
encouraging the child to assume a position of comfort, and obtaining parental permission for
administration of acetaminophen or aspirin are not immediate priorities. The application of
ice can reduce the severity of the injury.
DIF: Cognitive Level: Apply
REF: p. 947
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. Which term is used to describe a type of fracture that does not produce a break in the skin?
a. Simple
b. Compound
c. Complicated
d. Comminuted
ANS: A
If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture. A
compound, or open, fracture is one with an open wound through which the bone protrudes. A
complicated fracture is one in which the bone fragments damage other organs or tissues. A
comminuted fracture occurs when small fragments of bone are broken from the fractured
shaft and lie in the surrounding tissue. These are rare in children.
DIF: Cognitive Level: Understand
REF: p. 948
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she
fell off of a tree. When discussing this injury with her parents, the nurse should consider
which statement?
a. Healing is usually delayed in this type of fracture.
b. Growth can be affected by this type of fracture.
c. This is an unusual fracture site in young children.
d. This type of fracture is inconsistent with a fall.
ANS: B
Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis
or epiphyseal plate present special problems in determining whether bone growth will be
affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point
of the long bones. This is a frequent site of damage during trauma.
DIF: Cognitive Level: Apply
REF: p. 949
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. The nurse is conducting a staff in-service on casts. Which is an advantage to using a
fiberglass cast instead of a plaster of Paris cast?
Cheaper
Dries rapidly
Molds closely to body parts
Smooth exterior
a.
b.
c.
d.
ANS: B
A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which
takes 10 to 72 hours to dry. Synthetic casts are more expensive and have a rough exterior,
which may scratch surfaces. Plaster casts mold closer to body parts.
DIF: Cognitive Level: Apply
REF: p. 952
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is
being discharged with a cast. Which instruction should be included in the teaching?
Swelling of the fingers is to be expected for the next 48 hours.
Immobilize the shoulder to decrease pain in the arm.
Allow the affected limb to hang down for 1 hour each day.
Elevate casted arm when resting and when sitting up.
a.
b.
c.
d.
ANS: D
The injured extremity should be kept elevated while resting and in a sling when upright. This
will increase venous return. Swelling of the fingers may indicate neurovascular damage and
should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints
above and below the cast on the affected extremity should be moved. The affected limb
should not hang down for any length of time.
DIF: Cognitive Level: Apply
REF: p. 952
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. The nurse uses the palms of the hands when handling a wet cast for which reason?
a. To assess dryness of the cast
b. To facilitate easy turning
c. To keep the patient’s limb balanced
d. To avoid indenting the cast
ANS: D
Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating
pressure points. Assessing dryness, facilitating easy turning, and keeping the patient’s limb
balanced are not reasons for using the palms of the hand rather than the fingers when
handling a wet cast.
DIF: Cognitive Level: Understand
REF: p. 952
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. Which should cause a nurse to suspect that an infection has developed under a cast?
a. Complaint of paresthesia
b. Cold toes
c. Increased respirations
d. “Hot spots” felt on cast surface
ANS: D
If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This
should be reported so that a window can be made in the cast to observe the site. The five Ps
of ischemia from a vascular injury are pain, pallor, pulselessness, paresthesia, and paralysis.
Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of
too tight a cast and need further evaluation. Increased respirations may be indicative of a
respiratory tract infection or pulmonary emboli. This should be reported, and child should be
evaluated.
DIF: Cognitive Level: Analyze
REF: p. 952
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. A child is upset because when the cast is removed from her leg, the skin surface is caked with
desquamated skin and sebaceous secretions. Which should the nurse suggest to remove this
material?
a. Soak in a bathtub.
b. Vigorously scrub leg.
c. Apply powder to absorb material.
d. Carefully pick material off leg.
ANS: A
Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin
and sebaceous secretions. It may take several days to eliminate the accumulation completely.
The parents and child should be advised not to scrub the leg vigorously or forcibly remove
this material because it may cause excoriation and bleeding. Oil or lotion, but not powder,
may provide comfort for the child.
DIF: Cognitive Level: Apply
REF: p. 953
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. An adolescent with a fractured femur is in Russell’s traction. Surgical intervention to correct
the fracture is scheduled for the morning. Nursing actions should include which action?
a. Maintaining continuous traction until 1 hour before the scheduled surgery
b. Maintaining continuous traction and checking position of traction frequently
c. Releasing traction every hour to perform skin care
d. Releasing traction once every 8 hours to check circulation
ANS: B
When the muscles are stretched, muscle spasm ceases and permits realignment of the bone
ends. The continued maintenance of traction is important during this phase because releasing
the traction allows the muscle’s normal contracting ability to again cause malpositioning of
the bone ends. Continuous traction must be maintained to keep the bone ends in satisfactory
realignment. Releasing at any time, either 1 hour before surgery, once every hour for skin
care, or once every 8 hours would not keep the fracture in satisfactory alignment.
DIF: Cognitive Level: Apply
REF: p. 955
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. Which is a type of skin traction with the legs in an extended position?
a. Dunlop
b. Bryant
c. Russell
d. Buck extension
ANS: D
Buck extension traction is a type of skin traction with the legs in an extended position. It is
used primarily for short-term immobilization, preoperatively with dislocated hips, for
correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease. Dunlop
traction is an upper-extremity traction used for fractures of the humerus. Bryant traction is
skin traction with the legs flexed at a 90-degree angle at the hip. Russell traction uses skin
traction on the lower leg and a padded sling under the knee. The combination of longitudinal
and perpendicular traction allows realignment of the lower extremity and immobilizes the
hips and knees in a flexed position.
DIF: Cognitive Level: Understand
REF: p. 955
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. Which type of traction uses skin traction on the lower leg and a padded sling under the knee?
a. Dunlop
b. Bryant
c. Russell
d. Buck extension
ANS: C
Russell traction uses skin traction on the lower leg and a padded sling under the knee. The
combination of longitudinal and perpendicular traction allows realignment of the lower
extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an
upper-extremity traction used for fractures of the humerus. Bryant traction is skin traction
with the legs flexed at a 90-degree angle at the hip. Buck extension traction is a type of skin
traction with the legs in an extended position. It is used primarily for short-term
immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone
deformities such as Legg-Calvé-Perthes disease.
DIF: Cognitive Level: Understand
REF: p. 955
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. Four-year-old David is placed in Buck extension traction for Legg-Calvé-Perthes disease. He
is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence
of pulse. Which action should the nurse take first?
a. Notify the practitioner of the changes noted.
b. Give the child medication to relieve the pain.
c. Reposition the child and notify physician.
d. Chart the observations and check the extremity again in 15 minutes.
ANS: A
The absence of a pulse and change in color of the foot must be reported immediately for
evaluation by the practitioner. Pain medication should be given after the practitioner is
notified. Legg-Calvé-Perthes disease is an emergency condition; immediate reporting is
indicated. The findings should be documented with ongoing assessment.
DIF: Cognitive Level: Apply
REF: p. 955
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. Which is an appropriate nursing intervention when caring for a child in traction?
a. Remove adhesive traction straps daily to prevent skin breakdown.
b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles.
c. Provide active range-of-motion exercises to affected extremity three times a day.
d. Keep the child in one position to maintain good alignment.
ANS: B
Traction places stress on the affected bone, joint, and muscles. The nurse must assess for
tightness, weakness, or contractures developing in the uninvolved joints and muscles. The
adhesive straps should be released or replaced only when absolutely necessary. Active,
passive, or active with resistance exercises should be carried out for the unaffected extremity
only. Movement is expected with children. Each time the child moves, the nurse should check
to ensure that proper alignment is maintained.
DIF: Cognitive Level: Apply
REF: p. 955
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. The nurse is teaching a family how to care for their infant in a Pavlik harness to treat
developmental dysplasia of the hip. Which should be included?
a. Apply lotion or powder to minimize skin irritation.
b. Remove harness several times a day to prevent contractures.
c. Return to clinic every 1 to 2 weeks.
d. Place diaper over harness, preferably using a superabsorbent disposable diaper that
is relatively thin.
ANS: C
Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1
to 2 weeks for possible adjustments. Lotions and powders should not be used with the
harness. The harness should not be removed, except as directed by the practitioner. A thin
disposable diaper can be placed under the harness.
DIF: Cognitive Level: Apply
REF: p. 962
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
19. A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the
nurse how this will be corrected, the nurse should give which explanation?
Traction is tried first.
Surgical intervention is needed.
Frequent, serial casting is tried first.
Children outgrow this condition when they learn to walk.
a.
b.
c.
d.
ANS: C
Serial casting is begun shortly after birth before discharge from nursery. Successive casts
allow for gradual stretching of skin and tight structures on the medial side of the foot.
Manipulation and casting of the leg are repeated frequently (every week) to accommodate the
rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention
is done only if serial casting is not successful. Children do not improve without intervention.
DIF: Cognitive Level: Apply
REF: p. 963
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing
considerations should include which action?
Encouraging normal activity for as long as is possible
Explaining the cause of the disease to the child and family
Preparing the child and family for long-term, permanent disabilities
Teaching the family the care and management of the corrective appliance
a.
b.
c.
d.
ANS: D
The family needs to learn the purpose, function, application, and care of the corrective device
and the importance of compliance to achieve the desired outcome. The initial therapy is rest
and non–weight bearing, which helps reduce inflammation and restore motion. Legg-CalvéPerthes is a disease with an unknown etiology. A disturbance of circulation to the femoral
capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is
self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and
the child’s age at onset.
DIF: Cognitive Level: Apply
REF: p. 965
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse is taking care of an adolescent diagnosed with kyphosis. Which describes this
condition?
a. Lateral curvature of the spine
b. Immobility of the shoulder joint
c. Exaggerated concave lumbar curvature of the spine
d. Increased convex angulation in the curve of the thoracic spine
ANS: D
Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.
Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation
causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint.
Lordosis is an exaggerated concave lumbar curvature of the spine.
DIF: Cognitive Level: Understand
REF: p. 967
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A school nurse is conducting a staff in-service to other school nurses on idiopathic scoliosis.
During which period of child development does idiopathic scoliosis become most noticeable?
Newborn period
When child starts to walk
Preadolescent growth spurt
Adolescence
a.
b.
c.
d.
ANS: C
Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. Idiopathic
scoliosis is seldom apparent before age 10 years. Diagnosis usually occurs during the
preadolescent growth spurt.
DIF: Cognitive Level: Understand
REF: p. 968
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. The nurse is preparing an adolescent with scoliosis for a spinal surgical instrumentation
placement procedure. Which consideration should the nurse include?
A chest tube and urinary catheter may be required.
Ambulation will not be allowed for up to 3 months.
Surgery eliminates the need for casting and bracing.
Discomfort can be controlled with nonpharmacologic methods.
a.
b.
c.
d.
ANS: A
Surgical spinal instrumentation is a surgical procedure. A chest tube and urinary
catheterization may be required. Ambulation is allowed as soon as possible. Depending on
the instrumentation used, most patients walk by the second or third postoperative day.
Casting and bracing are required postoperatively. The child usually has considerable pain for
the first few days after surgery. Intravenous opioids should be administered on a regular
basis.
DIF: Cognitive Level: Apply
REF: p. 969
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. Which medication is usually tried first when a child is diagnosed with juvenile idiopathic
arthritis (JIA)?
a. Aspirin
b. Corticosteroids
c. Cytotoxic drugs such as methotrexate
d. Nonsteroidal antiinflammatory drugs (NSAIDs)
ANS: D
NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for
use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because
they have fewer side effects and easier administration schedules. Corticosteroids are used for
life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a secondline therapy for JIA.
DIF: Cognitive Level: Understand
REF: p. 972
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
25. The nurse is caring for a school-age child diagnosed with juvenile idiopathic arthritis (JIA).
Which intervention should be a priority?
a. Apply ice packs to relieve stiffness and pain.
b. Administer acetaminophen to reduce inflammation.
c. Teach the child and family correct administration of medications.
d. Encourage range-of-motion exercises during periods of inflammation.
ANS: C
The management of JIA is primarily pharmacologic. The family should be instructed
regarding administration of medications and the value of a regular schedule of administration
to maintain a satisfactory blood level in the body. They need to know that NSAIDs should not
be given on an empty stomach and to be alert for signs of toxicity. Warm moist heat is best
for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects.
Range-of-motion exercises should not be done during periods of inflammation.
DIF: Cognitive Level: Apply
REF: p. 972
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
26. The nurse is caring for a 12-year-old child with a left leg below-the-knee amputation (BKA).
The child had the surgery 1 week ago. Which intervention should the nurse plan to implement
for this child?
a. Elevate the left stump on a pillow.
b. Place an ice pack on the stump.
c. Encourage the child to use an overhead bed trapeze when repositioning.
d. Replace the ace wrap covering the stump with a gauze dressing.
ANS: C
Use of the overhead bed trapeze should be encouraged to begin to build up the arm muscles
necessary for walking with crutches. Stump elevation may be used during the first 24 hours,
but after this time, the extremity should not be left in this position because contractures in the
proximal joint will develop and seriously hamper ambulation. Ice would not be an
appropriate intervention and would decrease circulation to the stump. Stump shaping is done
postoperatively with special elastic bandaging using a figure-eight bandage, which applies
pressure in a cone-shaped fashion. This technique decreases stump edema, controls
hemorrhage, and aids in developing desired contours so the child will bear weight on the
posterior aspect of the skin flap rather than on the end of the stump. This wrap should not be
replaced with a gauze dressing.
DIF: Cognitive Level: Apply
REF: p. 957
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. A nurse is conducting discharge teaching for parents of an infant with osteogenesis
imperfecta (OI). Further teaching is indicated if the parents make which statement?
“We will be very careful handling the baby.”
“We will lift the baby by the buttocks when diapering.”
“We’re glad there is a cure for this disorder.”
“We will schedule follow-up appointments as instructed.”
a.
b.
c.
d.
ANS: C
The treatment for OI is primarily supportive. Although patients and families are optimistic
about new research advances, there is no cure. The use of bisphosphonate therapy with IV
pamidronate to promote increased bone density and prevent fractures has become standard
therapy for many children with OI; however, long bones are weakened by prolonged
treatment. Infants and children with this disorder require careful handling to prevent
fractures. They must be supported when they are being turned, positioned, moved, and held.
Even changing a diaper may cause a fracture in severely affected infants. These children
should never be held by the ankles when being diapered but should be gently lifted by the
buttocks or supported with pillows. Follow-up appointments for treatment with
bisphosphonate can be expected.
DIF: Cognitive Level: Analyze
REF: p. 964
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
28. The nurse is caring for an adolescent with osteosarcoma being admitted to undergo
chemotherapy. The adolescent had a right above-the-knee amputation 2 months ago and has
been experiencing “phantom limb pain.” Which prescribed medication is appropriate to
administer to relieve phantom limb pain?
a. Amitriptyline (Elavil)
b. Hydrocodone (Vicodin)
c. Oxycodone (OxyContin)
d. Alprazolam (Xanax)
ANS: A
Amitriptyline (Elavil) has been used successfully to decrease phantom limb pain. Opioids
such as Vicodin or OxyContin would not be prescribed for this pain. A benzodiazepine such
as Xanax would not be prescribed for this type of pain.
DIF: Cognitive Level: Apply
REF: p. 957
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical
manifestations should the nurse expect to observe? (Select all that apply.)
Positive Ortolani click
Unequal gluteal folds
Negative Babinski sign
Trendelenburg sign
Telescoping of the affected limb
Lordosis
a.
b.
c.
d.
e.
f.
ANS: A, B
A positive Ortolani test and unequal gluteal folds are clinical manifestations of developmental
dysplasia of the hip seen from birth to 2 to 3 months. Unequal gluteal folds, negative
Babinski sign, and Trendelenburg sign are signs that appear in older infants and children.
Telescoping of the affected limb and lordosis are not clinical manifestations of developmental
dysplasia of the hip.
DIF: Cognitive Level: Understand
REF: p. 959
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. An adolescent with juvenile idiopathic arthritis (JIA) is prescribed abatacept (Orencia).
Which should the nurse teach the adolescent regarding this medication? (Select all that
apply.)
a. Avoid receiving live immunizations while taking the medication.
b. Before beginning this medication, a tuberculin screening test will be done.
c. You will be getting a twice-a-day dose of this medication.
d. This medication is taken orally.
ANS: A, B
Abatacept reduces inflammation by inhibiting T cells and is given intravenously every 4
weeks. Possible side effects of biologics include an increased infection risk. Because of the
infection risk, children should be evaluated for tuberculosis exposure before starting these
medications. Live vaccines should be avoided while taking these agents.
DIF: Cognitive Level: Apply
REF: p. 972
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should
plan to implement which interventions for this child? (Select all that apply.)
Instructions to avoid exposure to sunlight
Teaching about body changes associated with SLE
Preparation for home schooling
Restricted activity
a.
b.
c.
d.
ANS: A, B
Key issues for a child with SLE include therapy compliance; body-image problems
associated with rash, hair loss, and steroid therapy; school attendance; vocational activities;
social relationships; sexual activity; and pregnancy. Specific instructions for avoiding
exposure to the sun and UVB light, such as using sunscreens, wearing sun-resistant clothing,
and altering outdoor activities, must be provided with great sensitivity to ensure compliance
while minimizing the associated feeling of being different from peers. The child should
continue school attendance in order to gain interaction with peers, and activity should not be
restricted but promoted.
DIF: Cognitive Level: Apply
REF: p. 975
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is caring for a preschool child with a cast applied recently for a fractured tibia.
Which assessment findings indicate possible compartment syndrome? (Select all that apply.)
a. Palpable distal pulse
b. Capillary refill to extremity less than 3 seconds
c. Severe pain not relieved by analgesics
d. Tingling of extremity
e. Inability to move extremity
ANS: C, D, E
Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of
extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the
extremity less than 3 seconds are expected findings.
DIF: Cognitive Level: Apply
REF: p. 950
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 30: The Child with Neuromuscular or Muscular Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is planning a staff in-service on childhood spastic cerebral palsy. What
characterizes spastic cerebral palsy?
Hypertonicity and poor control of posture, balance, and coordinated motion
Athetosis and dystonic movements
Wide-based gait and poor performance of rapid, repetitive movements
Tremors and lack of active movement
a.
b.
c.
d.
ANS: A
Hypertonicity and poor control of posture, balance, and coordinated motion are part of the
classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the
classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance
of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors
and lack of active movement may indicate other neurologic disorders.
DIF: Cognitive Level: Understand
REF: p. 978
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their
child’s spasticity. The nurse’s response should be based on which statement?
a. Anticonvulsant medications are sometimes useful for controlling spasticity.
b. Medications that would be useful in reducing spasticity are too toxic for use with
children.
c. Many different medications can be highly effective in controlling spasticity.
d. Implantation of a pump to deliver medication into the intrathecal space to decrease
spasticity has recently become available.
ANS: D
Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes
with activities of daily living and ambulation. Anticonvulsant medications are used when
seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects
of the drugs that reduce spasticity. Few medications are currently available for the control of
spasticity.
DIF: Cognitive Level: Understand
REF: p. 979
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
3. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive
care nursery. Which describes this newborn’s defect?
a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed
b. Herniation of the brain and meninges through a defect in the skull
c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural
elements
d. Visible defect with an external saclike protrusion containing meninges, spinal
fluid, and nerves
ANS: D
A myelomeningocele is a visible defect with an external saclike protrusion, containing
meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves
the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and
meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial
protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.
DIF: Cognitive Level: Understand
REF: p. 984
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is conducting a staff in-service on common problems associated with
myelomeningocele. Which common problem is associated with this defect?
a. Hydrocephalus
b. Craniostenosis
c. Biliary atresia
d. Esophageal atresia
ANS: A
Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniostenosis
is the preterm closing of the cranial sutures and is not associated with myelomeningocele.
Biliary and esophageal atresia is not associated with myelomeningocele.
DIF: Cognitive Level: Understand
REF: p. 984
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is teaching a group of nursing students about newborns born with the congenital
defect of myelomeningocele. Which common problem is associated with this defect?
Neurogenic bladder
Cognitive impairment
Respiratory compromise
Cranioschisis
a.
b.
c.
d.
ANS: A
Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder
dysfunction among children. Risk of cognitive impairment is minimized through early
intervention and management of hydrocephalus. Respiratory compromise is not a common
problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues
protrude. It is not associated with myelomeningocele.
DIF: Cognitive Level: Understand
REF: p. 987
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is reviewing prenatal vitamin supplements with an expectant client. Which
supplement should be included in the teaching?
Vitamin A throughout pregnancy
Multivitamin preparations as soon as pregnancy is suspected
Folic acid for all women of childbearing age
Folic acid during the first and second trimesters of pregnancy
a.
b.
c.
d.
ANS: C
The widespread use of folic acid among women of childbearing age has decreased the
incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina
bifida. Folic acid supplementation is recommended for the preconception period and during
the pregnancy. Only 42% of women actually follow these guidelines.
DIF: Cognitive Level: Understand
REF: p. 988
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. How much folic acid is recommended for women of childbearing age?
a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg
ANS: B
It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age
will prevent 50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0
mg are not the recommended dosages of folic acid.
DIF: Cognitive Level: Remember
REF: p. 988
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
8. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect
is scheduled the next day. Which describes the most appropriate way to position and feed this
neonate?
a. Prone and tube-fed
b. Prone, head turned to side, and nipple-fed
c. Supine in an infant carrier and nipple-fed
d. Supine, with defect supported with rolled blankets, and nipple-fed
ANS: B
In the prone position, feeding is a problem. The infant’s head is turned to one side for
feeding. If the child is able to nipple-feed, tube feeding is not needed. Before surgery, the
infant is kept in the prone position to minimize tension on the sac and risk of trauma.
DIF: Cognitive Level: Apply
REF: p. 988
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. The nurse is talking to a parent with a child who has a latex allergy. Which statement by the
parent would indicate a correct understanding of the teaching?
a. “My child will have an allergic reaction if he comes in contact with yeast
products.”
b. “My child may have an upset stomach if he eats a food made with wheat or
barley.”
c. “My child will probably develop an allergy to peanuts.”
d. “My child should not eat bananas or kiwis.”
ANS: D
There are cross-reactions between latex allergies and a number of foods such as bananas,
avocados, kiwi, and chestnuts. Children with a latex allergy will not develop allergies to other
food products such as yeast, wheat, barley, or peanuts.
DIF: Cognitive Level: Analyze
REF: p. 990
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions
include which action?
Avoid using any latex product.
Use only nonallergenic latex products.
Administer medication for long-term desensitization.
Teach family about long-term management of asthma.
a.
b.
c.
d.
ANS: A
Care must be taken that individuals who are at high risk for latex allergies do not come in
direct or secondary contact with products or equipment containing latex at any time during
medical treatment. There are no nonallergenic latex products. At this time, desensitization is
not an option. The child does not have asthma. The parents must be taught about allergy and
the risk of anaphylaxis.
DIF: Cognitive Level: Apply
REF: p. 990
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type
1). Which signs and symptoms are associated with this disease?
Spinal muscular atrophy
Neural atrophy of muscles
Progressive weakness and wasting of skeletal muscle
Pseudohypertrophy of certain muscle groups
a.
b.
c.
d.
ANS: C
Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic
form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive
weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells.
Kugelberg-Welander disease is a juvenile spinal muscular atrophy with a later onset. CharcotMarie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the
peroneal nerves. Progressive weakness is found of the distal muscles of the arms and feet.
Duchenne muscular dystrophy is characterized by muscles, especially in the calves, thighs,
and upper arms, which become enlarged from fatty infiltration and feel unusually firm or
woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.
DIF: Cognitive Level: Understand
REF: p. 991
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy
(Werdnig-Hoffmann disease)?
a. Hyperactive deep tendon reflexes
b. Hypertonicity
c. Lying in the frog position
d. Motor deficits on one side of body
ANS: C
The infant lies in the frog position with the legs externally rotated, abducted, and flexed at the
knees. The deep tendon reflexes are absent. The child has hypotonia and inactivity as the
most prominent features. The motor deficits are bilateral.
DIF: Cognitive Level: Understand
REF: p. 991
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular
dystrophy. The management plan should include which action?
Recommend genetic counseling.
Explain that the disease is easily treated.
Suggest ways to limit use of muscles.
Assist family in finding a nursing facility to provide child’s care.
a.
b.
c.
d.
ANS: A
Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive
gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and
their female offspring. No effective treatment exists at this time for childhood muscular
dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary
goal. It has been found that children who remain as active as possible are able to avoid
wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to
provide the child’s care is inappropriate at the time of diagnosis. When the child becomes
increasingly incapacitated, the family may consider home-based care, a skilled nursing
facility, or respite care to provide the necessary care.
DIF: Cognitive Level: Understand
REF: p. 992
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. What should be administered to a child with tetanus?
a. Nonsteroidal antiinflammatory drugs (NSAIDs) to reduce inflammation.
b. Muscle stimulants to counteract muscle weakness.
c. Bronchodilators to prevent respiratory complications.
d. Tetanus immunoglobulin therapy.
ANS: D
Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus.
Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the
threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle
relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is
carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives
that may be prescribed may cause respiratory depression. Bronchodilators would not be used
unless specifically indicated.
DIF: Cognitive Level: Understand
REF: p. 997
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding
should be reported as abnormal and considered as a possible sign of cerebral palsy?
Tonic neck reflex at 5 months of age
Absent Moro reflex at 8 months of age
Moro reflex at 3 months of age
Extensor reflex at 7 months of age
a.
b.
c.
d.
ANS: D
Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of
primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex
(beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally
disappears between 4 and 6 months of age. The crossed extensor reflex, which normally
disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with
the knee extended. Normally, the contralateral foot responds with extensor, abduction, and
then adduction movements. The possibility of CP is suggested if these reflexes occur after 4
months.
DIF: Cognitive Level: Apply
REF: p. 979
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the
morning. Which intervention should the nurse plan for the care of the myelomeningocele sac?
Open to air
Covered with a sterile, moist, nonadherent dressing
Reinforcement of the original dressing if drainage noted
A diaper secured over the dressing
a.
b.
c.
d.
ANS: B
Before surgical closure, the myelomeningocele is prevented from drying by the application of
a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually
sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is
closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be
carefully cleansed if it becomes soiled or contaminated. The original dressing would not be
reinforced but changed as needed. A diaper is not placed over the dressing because stool
contamination can occur.
DIF: Cognitive Level: Apply
REF: p. 987
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. The nurse is admitting a school-age child with suspected Guillain-Barré syndrome (GBS).
Which is a priority in the care for this child?
Monitoring intake and output
Assessing respiratory efforts
Placing on a telemetry monitor
Obtaining laboratory studies
a.
b.
c.
d.
ANS: B
Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized
because respiratory and pharyngeal involvement may require assisted ventilation, sometimes
with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in
the event of respiratory compromise, intravenous (IV) administration of immunoglobulin
(IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be
used. Intake and output, telemetry monitoring, and obtaining laboratory studies may be part
of the plan of care but are not the priority.
DIF: Cognitive Level: Analyze
REF: p. 996
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit.
Which health care provider prescription should the nurse clarify with the health care provider
before implementing?
a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time.
b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously.
c. Titrate oxygen to keep pulse oximetry saturations greater than 92.
d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback
every 12 hours.
ANS: D
The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic
therapy is not part of the management of infant botulism because the botulinum toxin is an
intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular
should not be administered because they may potentiate the blocking effects of the
neurotoxin. Treatment consists of immediate administration of botulism immune globulin
intravenously (BIG-IV) without delaying for laboratory diagnosis. Early administration of
BIG-IV neutralizes the toxin and stops the progression of the disease. The human-derived
botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only
in infant botulism. Approximately 50% of affected infants require intubation and mechanical
ventilation; therefore, respiratory support is crucial, as is nutritional support, because these
infants are unable to feed.
DIF: Cognitive Level: Analyze
REF: p. 999
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent
suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the
nurse perform first?
a. Place the adolescent in a flat right side-lying position.
b. Place a cool washcloth on the adolescent’s forehead and continue to monitor the
blood pressure.
c. Implement a standing prescription to empty the bladder with a sterile in and out
Foley catheter.
d. Take a full set of vital signs and notify the health care provider.
ANS: C
The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of
autonomic function is replaced by autonomic dysreflexia, especially when the lesions are
above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or
irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to
the cord lesion, where they are blocked, which causes activation of sympathetic reflex action
with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a
flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and
bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other
internal or external sensory input. It can be a catastrophic event unless the irritation is
relieved. Placing a cool washcloth on the adolescent’s forehead, continuing to monitor blood
pressure and vital signs, and notifying the health care provider would not reverse the
sympathetic reflex situation.
DIF: Cognitive Level: Apply
REF: p. 1000
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. A child steps on a nail and sustains a puncture wound of the foot. Which is the most
appropriate method for cleansing this wound?
Wash wound thoroughly with chlorhexidine.
Wash wound thoroughly with povidone-iodine.
Soak foot in warm water and soap.
Soak foot in solution of 50% hydrogen peroxide and 50% water.
a.
b.
c.
d.
ANS: C
Puncture wounds should be cleansed by soaking the foot in warm water and soap.
Chlorhexidine, hydrogen peroxide, and povidone-iodine should not be used because they
have a cytotoxic effect on healthy cells and minimal effect on controlling infection.
DIF: Cognitive Level: Apply
REF: p. 998
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing
care for this child includes which action(s)? (Select all that apply.)
a. Monitoring and maintaining systemic blood pressure
b.
c.
d.
e.
Administering corticosteroids
Minimizing environmental stimuli
Discussing long-term care issues with the family
Monitoring for respiratory complications
ANS: A, B, E
Spinal cord injury patients are physiologically labile, and close monitoring is required. They
may be unstable for the first few weeks after the injury. Corticosteroids are administered to
minimize the inflammation present with the injury. It is not necessary to minimize
environmental stimuli for this type of injury. Discussing long-term care issues with the family
is inappropriate. The family is focusing on the recovery of their child. It will not be known
until the rehabilitation period how much function the child may recover.
DIF: Cognitive Level: Apply
REF: p. 1000
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which assessment findings should the nurse note in a school-age child with Duchenne
muscular dystrophy (DMD)? (Select all that apply.)
a. Lordosis
b. Gower sign
c. Kyphosis
d. Scoliosis
e. Waddling gait
ANS: A, B, E
Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms
noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and
lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or
sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic
muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus
muscles. Kyphosis and scoliosis are not assessment findings with DMD.
DIF: Cognitive Level: Apply
REF: p. 992
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is conducting discharge teaching to parents of a preschool child with
myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract
infection (UTI). Which should the nurse include in the discharge instructions related to
management of the child’s genitourinary function? (Select all that apply.)
a. Continue to perform the clean intermittent catheterizations (CIC) at home.
b. Administer the oxybutynin chloride (Ditropan) as prescribed.
c. Reduce fluid intake in the afternoon and evening hours.
d. Monitor for signs of a recurrent urinary tract infection.
e. Administer furosemide (Lasix) as prescribed.
ANS: A, B, D
Discharge teaching to prevent renal complications in a child with myelomeningocele include:
(1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of
regular emptying of the bladder, such as CIC taught to and performed by parents and selfcatheterization taught to children; (3) medications to improve bladder storage and continence,
such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited
and Lasix is not used to improve renal function for children with myelomeningocele.
DIF: Cognitive Level: Apply
REF: p. 984
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with
Guillain-Barré syndrome (GBS)? (Select all that apply.)
Decreased protein concentration
Normal glucose
Fewer than 10 white blood cells (WBCs/mm3)
Elevated red blood cell (RBC) count
a.
b.
c.
d.
ANS: B, C
Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF
analysis reveals an abnormally elevated protein concentration, normal glucose, and fewer
than 10 WBCs/mm3. CSF fluid should not contain RBCs.
DIF: Cognitive Level: Understand
REF: p. 996
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele
scheduled for surgical repair in the morning. Which early signs of infection should the nurse
monitor on this infant? (Select all that apply.)
a. Temperature instability
b. Irritability
c. Lethargy
d. Bradycardia
e. Hypertension
ANS: A, B, C
The nurse should observe an infant with unrepaired myelomeningocele for early signs of
infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and
hypertension are not early signs of infection in infants.
DIF: Cognitive Level: Analyze
REF: p. 989
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
SHORT ANSWER
1. A toddler is admitted to the hospital with a possible diagnosis of tetanus. The health care
provider has prescribed lorazepam (Ativan) intravenously 0.05 mg/kg/dose every 6 hours prn
as a muscle relaxant. The child weighs 22 pounds. How many milligrams of Ativan should
the nurse administer per dose? (Record your answer using one decimal place.)
ANS:
0.5
Find the child’s weight in kilograms by dividing 22 by 2.2 = 22/2.2 = 10 kg. Multiply the
0.05 mg dose by 10 = 0.05 mg ´ 10 kg = 0.5 mg per dose.
DIF: Cognitive Level: Analyze
REF: p. 998
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies