Essentials of Pediatric Nursing 4th Edition Kyle Carman Test Bank
CHAPTER 1 Introduction to Child Health and Pediatric Nursing
MULTIPLE CHOICE
1. A nurse is planning a teaching session for parents of preschool children. Which
statement explains 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 6-8
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 3
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.
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PTS: 1 DIF: Cognitive Level: Remember REF: 7
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 AfricanAmerican boys ranging in ages 15 to 19 years?
a. Suicide
b. Cancer
c. Firearm homicide
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 5 | 8
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 8
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. Mechanical suffocation
b. Drowning
c. Motorvehicle-related fatalities
d. Fire- and burn-related fatalities
ANS: C
Motorvehicle-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. Fire- and burn-related fatalities are the second-leading cause of
death.
PTS: 1 DIF: Cognitive Level: Remember REF: 4
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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7. Which factor most impacts the type of injury a child is susceptible to, according to the
childs age?
a. Physical health of the child
b. Developmental level of the child
c. Educational level of the child
d. Number of responsible adults in the home
ANS: B
The childs developmental stage determines the type of injury that is likely to occur. The
childs physical health may facilitate the childs 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 childs 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 childs developmental stage.
PTS: 1 DIF: Cognitive Level: Understand REF: 3-4
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 living
b. Unintentional injuries that cause chronic health problems
c. Discoveries of new therapies to treat health problems
d. Behavioral, social, and educational problems that alter health
ANS: D
The new morbidity reflects the behavioral, social, and educational problems that interfere
with the childs 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 3
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. Taking over total care of the child to reduce stress on the family
b. Encouraging family dependence on health care systems
c. Recognizing that the family is the constant in a childs life
d. 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 childs 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 8
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
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10. The nurse is preparing an in-service education to staff about atraumatic care for
pediatric patients. 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 treatment or procedure by demonstrating on a
stuffed animal.
c. Help the child accept the loss of control associated 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 9
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 family?
a. Staff is concerned about the nurses actions with the patient and family.
b. Staff assignments allow the nurse to care for same patient and family over an extended
time.
c. Nurse is able to withdraw emotionally when emotional overload occurs but still
remains committed.
d. Nurse uses teaching skills to instruct patient and family rather than doing everything
for them.
ANS: A
An important 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 9
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 12
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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 childs skin before
drawing blood. Which ethical principle is the nurse demonstrating?
a. Autonomy
b. Beneficence
c. Justice
d. Truthfulness
ANS: B
Beneficence is the obligation to promote the patients well-being. Applying a topical
anesthetic before drawing blood promotes reducing the discomfort of the venipuncture.
Autonomy is the patients right to be self-governing. Justice is the concept of fairness.
Truthfulness is the concept of honesty.
PTS: 1 DIF: Cognitive Level: Understand REF: 11
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 patients status
c. Questioning the use of daily central line dressing changes
d. Clarifying a physicians prescription for morphine
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
evidence-based practice (EBP), which implies questioning why something is effective
and whether a better approach exists. Gathering equipment for a procedure and
documenting changes in a patients status are practices that follow established guidelines.
Clarifying a physicians prescription for morphine constitutes safe nursing care.
PTS: 1 DIF: Cognitive Level: Apply REF: 11
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 sitting comfortably on a parents 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 12
TOP: Integrated Process: Nursing Process: Diagnosis
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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 completed, child tolerated procedure well,
parent present
b. No complications noted during dressing change to appendectomy incision
c. Appendectomy incision non-reddened, sutures intact, no drainage noted on old
dressing, new dressing applied, procedure tolerated well by child
d. 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 patients 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 childs response. The other statements partially fulfill the requirements of
documenting assessments and reassessments, patients response, and outcome, but do not
include all three.
PTS: 1 DIF: Cognitive Level: Analyze REF: 14
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. Appropriate use of car seat restraints
b. Safety crossing the street
c. Helmet use when riding a bicycle
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 3-4
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which behaviors by the nurse indicate a therapeutic relationship with children and
families? (Select all that apply.)
a. Spending off-duty time with children and families
b. Asking questions if families are not participating in the care
c. Clarifying information for families
d. Buying toys for a hospitalized child
e. Learning about the familys religious preferences
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ANS: B, C, E
Asking questions if families are not participating in the care, clarifying information for
families, and learning about the familys 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 9-10
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
ESSAY
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.
CHAPTER 2 Factors Influencing Child Health
MULTIPLE CHOICE
1. A nurse is selecting a family theory to assess a patients family dynamics. Which family
theory best describes a series of tasks for the family throughout its life span?
a. Interactional theory
b. Developmental systems theory
c. Structural-functional theory
d. Duvalls developmental theory
ANS: D
Duvalls 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 Duvalls 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 24-26
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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2. Which family theory explains how families react to stressful events and suggests
factors that promote adaptation to these events?
a. Interactional theory
b. Developmental systems theory
c. Family stress theory
d. Duvalls developmental theory
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
Duvalls 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. Duvalls developmental theory describes
eight developmental tasks of the family throughout its life span.
PTS: 1 DIF: Cognitive Level: Understand REF: 24
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 step-parent, 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 24-26
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is assessing a familys structure. Which describes a family in which a mother,
her children, and a stepfather live together?
a. Blended
b. Nuclear
c. Binuclear
d. Extended
ANS: A
A blended family contains at least one step-parent, 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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 24-26
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which is considered characteristic of children who are the youngest in their family?
a. More dependent than firstborn children
b. More outgoing than firstborn children
c. Identify more with parents than with peers
d. Are subject to greater parental expectations
ANS: B
Later-born children are obliged to interact with older siblings from birth and seem to be
more outgoing and make friends more easily than firstborns. Being more dependent,
identifying more with parents than peers, and being subject to greater parental
expectations are characteristics of firstborn children and only children.
PTS: 1 DIF: Cognitive Level: Understand REF: 29-30
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 29
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. A 35-year-old client is currently on fertility treatments. When responding to a question
from the client about multiple births, which statement by the nurse is accurate?
a. Use of fertility treatments has been associated with an increase in multiple births.
b. Your chance of having multiple births is at the same rate as all women of childbearing
age.
c. There is not enough evidence about the use of fertility treatments increasing the rate of
multiple births.
d. Because of your age and the fertility treatments, you have almost a 100% chance of a
multiple birth.
ANS: A
Because women in their thirties are almost 2.5 times as likely as women in their twenties
to have higher-order plural births, increased childbearing among older women and the
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expanded use of fertility drugs have been associated with an increase in the multiple-birth
ratio. The rate of having a multiple birth for this client is not the same for all women of
childbearing age. There are data indicating that fertility treatments increase the rate of
multiple births, but fertility treatments do not have a 100% rate of multiple births.
PTS: 1 DIF: Cognitive Level: Understand REF: 30
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance: Family Systems
8. Nicole and Kelly, age 5 years, are identical twins. Their parents tell the nurse that the
girls always want to be together. The nurses suggestions should be based on which
statement?
a. Some twins thrive best when they are constantly together.
b. Individuation cannot occur if twins are together too much.
c. Separating twins at an early age helps them develop mentally.
d. When twins are constantly together, pathologic bonding occurs.
ANS: A
Twins work out a relationship that is reasonably satisfactory to both. They develop a
remarkable capacity for cooperative play and considerable loyalty and generosity toward
each other. Parents should foster individual differences and allow the children to follow
their natural inclinations. Individuation does occur. In twinship, one member of the pair is
more dominant, outgoing, and assertive than the other. Early separation may produce
unnecessary stresses for the children. There is no evidence that pathologic bonding occurs
when twins are constantly together.
PTS: 1 DIF: Cognitive Level: Understand REF: 30-31
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
9. 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 parents 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 31-32
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. When assessing a family, the nurse determines that the parents exert little or no
control over their children. This style of parenting is called:
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a. permissive.
b. dictatorial.
c. democratic.
d. authoritarian.
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 childrens actions. Dictatorial or authoritarian parents attempt to control
their childrens 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 childrens behavior and attitudes by emphasizing the reasons for rules and
negatively reinforcing deviations. They respect the childs individual nature.
PTS: 1 DIF: Cognitive Level: Remember REF: 33
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
11. When discussing discipline with the mother of a 4-year-old child, the nurse should
include which instruction?
a. Children as young as 4 years old rarely need to be punished.
b. Parental control should be consistent.
c. Withdrawal of love and approval is effective at this age.
d. One should expect rules to be followed rigidly and unquestioningly.
ANS: B
For effective discipline, parents must be consistent and must follow through with agreedon 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 childs age, temperament, and severity of the misbehavior. Following rules rigidly and
unquestioningly is beyond the developmental capabilities of a 4-year-old.
PTS: 1 DIF: Cognitive Level: Apply REF: 33
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
12. 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. Childrens 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
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severe corporal punishment each time. The use of corporal punishment may interfere with
the childs development of moral reasoning.
PTS: 1 DIF: Cognitive Level: Understand REF: 35
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. 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 childs 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 36
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. 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 parent, or an unusual response that indicates need for
referral in school-age children after parental divorce.
PTS: 1 DIF: Cognitive Level: Apply REF: 37
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
15. 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 dont want Eric to suffer because Ill have less
time with him. The nurses most appropriate answer would be which statement?
a. Im sure hell 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. Lets talk about the child-care options that will be best for Eric.
ANS: D
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Lets 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. Im sure hell 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 40
TOP: Integrated Process: Communication and Documentation
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 28
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
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home. The time-out should not be spent in an area from which the child can view the
television. Select an area for time-out that is safe, convenient, and unstimulating but
where the child can be monitored, such as the bathroom, hallway, or laundry room.
PTS: 1 DIF: Cognitive Level: Apply REF: 35
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 type 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. They 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 38
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 41
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A parent of a newborn is expressing concern about returning to work after taking time
off under the Family and Medical Leave Act (FMLA). The nurse understands that the Act
allows a new parent to take off from work for _____ weeks. (Record your answer as a
whole number.)
ANS:
12
The passage of the Family and Medical Leave Act (FMLA) in 1993 set the stage for a
greater focus on the issues of contemporary families. FMLA allows eligible employees to
take up to 12 weeks of unpaid leave each year to care for newborn or newly adopted
children, parents, or spouses who have serious health conditions or to recover from their
own serious health condition.
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CHAPTER 3 Growth and Development of the Newborn and Infant
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?
a. Caput succedaneum
b. Hydrocephalus
c. Cephalhematoma
d. Subdural hematoma
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 230
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 babys facial nerve paralysis.
The nurses response is based on knowledge that this is caused by a(n):
a. genetic defect.
b. birth injury.
c. spinal cord injury.
d. inborn error of metabolism.
ANS: B
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 231
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. The nurse
should reassure her that this is:
a. easily treated.
b. benign and transient.
c. usually not contagious.
d. usually not disfiguring.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 232
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-to-person transmission; and contaminated bottles, hands, or other
objects.
PTS: 1 DIF: Cognitive Level: Understand REF: 232
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Nursing care of the newborn with oral candidiasis (thrush) includes:
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 234
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. The nurses response should be based on knowledge that:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 234
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?
a. Postterm
b. Premature
c. Low birth weight
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d. Small for gestational age
ANS: B
A premature 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 lowbirth-weight newborn is a child whose birth weight
is less than 2500 g, regardless of gestational age. A small-for-gestational-age (or smallfor-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.
PTS: 1 DIF: Cognitive Level: Remember REF: 236
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 lowbirth-weight newborn is a child
whose birth weight is less than 2500 g, regardless of gestational age.
PTS: 1 DIF: Cognitive Level: Remember REF: 236
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. The nurse is caring for a very lowbirth-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.
PTS: 1 DIF: Cognitive Level: Understand REF: 240
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?
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 240
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 240
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?
a. Allow formula to flow by gravity.
b. Insert tube through nares rather than mouth.
c. Avoid letting newborn suck on tube.
d. Apply steady pressure to syringe to deliver formula to stomach in a timely manner.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 242
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 244
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
premature 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 premature 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 newborns skin must be cleaned to remove stool and urine,
which are irritating to the skin.
PTS: 1 DIF: Cognitive Level: Apply REF: 244
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
premature 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 premature 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 244
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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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 newborns diaper, the nurse observes the
newborns 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 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?
a. As soon as possible after newborn is born
b. As soon as parent is available to provide stimulation
c. When newborn is over 38 weeks of gestation
d. When developmental organization and stability are sufficient
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 childs cues, but the stimulation
should not depend on the familys availability. An individualized stimulation program
should be started when the child is developmentally ready.
PTS: 1 DIF: Cognitive Level: Analyze REF: 248
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. The nurse should recognize that this is:
a. normal.
b. a reason to postpone discharge.
c. suggestive of maladaptation.
d. suggestive of inadequate bonding.
ANS: A
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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.
21. Recent studies indicate that a deficiency of which vitamin correlates with increased
morbidity and mortality in children with measles?
a. A
b. C
c. Niacin
d. 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 vitamins C, niacin, or folic acid and measles.
PTS: 1 DIF: Cognitive Level: Remember REF: 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
22. Which vitamin is recommended for all women of childbearing age to reduce the risk
of neural tube defects such as spina bifida?
a. A
b. C
c. Niacin
d. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
23. A nurse is assessing a child with kwashiorkor disease. Which assessment findings
should the nurse expect?
a. Thin wasted extremities with a prominent abdomen
b. Constipation
c. Elevated hemoglobin
d. 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
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electrolyte imbalance. Anemia and protein deficiency is a common finding in
malnourished children with kwashiorkor.
PTS: 1 DIF: Cognitive Level: Understand REF: 357
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
24. A nurse is preparing to accompany a medical missions 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 357
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
25. Rickets is caused by a deficiency in:
a. vitamin A.
b. vitamin C.
c. vitamin D and calcium.
d. folic acid and iron.
ANS: C
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
26. 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
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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 Ccontaining juices enhance the absorption of
iron. Meat, fish, and poultry do not have an effect on absorption.
PTS: 1 DIF: Cognitive Level: Understand REF: 356
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
27. 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?
a. Niacin
b. B6
c. D
d. C
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 355
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
28. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 356
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
29. Which describes marasmus?
a. Deficiency of protein with an adequate supply of calories
b. Not confined to geographic areas where food supplies are inadequate
c. Syndrome that results solely from vitamin deficiencies
d. Characterized by thin, wasted extremities and a prominent abdomen resulting from
edema (ascites)
ANS: B
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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.
PTS: 1 DIF: Cognitive Level: Remember REF: 357
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
30. 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. cows milk and green vegetables.
d. eggs, cows 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. Cows milk is a common allergen, but green vegetables are
not.
CHAPTER 4 Growth and Development of the Toddler
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 379
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.
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The ability to get along with age-mates develops during the preschool and school-age
years.
PTS: 1 DIF: Cognitive Level: Understand REF: 380
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 380
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 nurses 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 379
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?
a. Trust
b. Preoperational
c. Secondary circular reaction
d. Tertiary circular reaction
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 Eriksons 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.
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PTS: 1 DIF: Cognitive Level: Remember REF: 380
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which is descriptive of a toddlers 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 381
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 381
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?
a. This is typical behavior because toddlers are aggressive.
b. This is typical behavior because toddlers are egocentric.
c. Toddlers should know that sharing toys is expected of them.
d. Toddlers should have the cognitive ability to know right from wrong.
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
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 385
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 382
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Which should the nurse expect for a toddlers 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 childs vocabulary. This is also true for bilingual
children, who are able to achieve this linguistic milestone in both languages. The 18month-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.
PTS: 1 DIF: Cognitive Level: Understand REF: 384
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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 385
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 379
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. The nurse should recognize in this situation that:
a. blocks at this age are used primarily for throwing.
b. toddlers are too young to imitate the behavior of others.
c. toddlers are capable of building a tower of blocks.
d. toddlers are too young to build a tower of blocks.
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 18-month-old child imitates others around him or her.
PTS: 1 DIF: Cognitive Level: Apply REF: 380
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. 15 months
b. 18 months
c. 24 months
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 384 | 387
TOP: Integrated Process: Nursing Process: Assessment
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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 nurses best
reply?
a. Lets see if we can figure out why he hates the new baby.
b. Thats a strong statement to come from such a small boy.
c. Lets refer him to counseling to work this hatred out. Its not a normal response.
d. That is a normal response to the birth of a sibling. Lets 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 newborns 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 dolls needs at the same time the parent
is performing similar care for the newborn.
PTS: 1 DIF: Cognitive Level: Apply REF: 389
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A toddlers 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 parents
presence is necessary both for safety and to provide a feeling of control and security to
the child when the tantrum is over.
PTS: 1 DIF: Cognitive Level: Apply REF: 389-390
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?
a. Punish the child.
b. Provide more attention.
c. Ask child not always to say no.
d. Reduce the opportunities for a no answer.
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 390
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 390
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 childrens way of
expressing stress. The parents should not introduce new expectations and allow the child
to master the developmental tasks without criticism.
PTS: 1 DIF: Cognitive Level: Apply REF: 389-390
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 390
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. The nurse should explain that this is:
a. a sign the child is spoiled.
b. a way to exert unhealthy control.
c. regression, common at this age.
d. ritualism, common at this age.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 391
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
22. Developmentally, most children at age 12 months:
a. use a spoon adeptly.
b. relinquish the bottle voluntarily.
c. eat the same food as the rest of the family.
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 391
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
23. The most effective way to clean a toddlers teeth is for the:
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
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For young children, the most effective cleaning of teeth is by the parents. Different
positions can be used if the childs back is to the adult. The adult should use one hand to
stabilize the chin and the other to brush the childs teeth. The child can participate in
brushing, but for a thorough cleaning, adult intervention is necessary.
PTS: 1 DIF: Cognitive Level: Understand REF: 394
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 395
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 396
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
26. Kimberlys 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.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 396 | 398
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.
The nurses rationale for this action is that they:
a. are low in nutritive value.
b. are 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 391
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 nurses best advice is:
a. All medicines should be locked securely away.
b. The medicines should be placed in high cabinets.
c. The child just needs to be taught not to touch medicines.
d. Medicines should not be kept in the homes of small children.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 402
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
29. The most fatal type of burn in the toddler age group is:
a. flame burn from playing with matches.
b. scald burn from high-temperature tap water.
c. hot object burn from cigarettes or irons.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 401
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?
a. Small plastic Lego
b. Set of large plastic building blocks
c. Brightly colored balloon
d. Coloring book and crayons
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 403
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 toddlers preoperational thinking is the nurse using?
a. Inability to conserve
b. Magical thinking
c. Centration
d. Irreversibility
ANS: A
The nurse is using the toddlers 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 382
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?
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a. Even if our toddler helps buckle the straps, we will double-check the fastenings.
b. We wont start the car until everyone is properly restrained.
c. We wont need to use the car seat on short trips to the store.
d. We will anchor the car seat to the cars 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 cars anchoring system and apply the harness snugly to the
child.
PTS: 1 DIF: Cognitive Level: Apply REF: 400
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which are characteristic of physical development of a 30-month-old child? (Select all
that apply.)
a. Birth weight has doubled.
b. Primary dentition is complete.
c. Sphincter control is achieved.
d. Anterior fontanel is open.
e. Length from birth is doubled.
f. Left or right handedness is established.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 387
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.)
a. Keep toxic substances in the garage.
b. Discard empty poison containers.
c. Know the number of the nearest poison control center.
d. Remove colorful labels from containers of toxic substances.
e. Caution child against eating nonedible items, such as plants.
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 397
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.)
a. Jumps in place with both feet
b. Takes a few steps on tiptoe
c. Throws ball overhand without falling
d. Pulls and pushes toys
e. Stands on one foot momentarily
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.
CHAPTER 5 Growth and Development of the Preschooler
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 twowheel bicycle, and skipping on alternate feet are gross motor skills of 5-year-olds.
PTS: 1 DIF: Cognitive Level: Understand REF: 408
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 numbers.
c. Draw a person with seven parts and correctly identify the parts.
d. 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 5year-olds.
PTS: 1 DIF: Cognitive Level: Understand REF: 408
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. According to Piaget, which describes magical thinking?
a. Events have cause and effect.
b. God is like an imaginary friend.
c. Thoughts are all-powerful.
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d. If the skin is broken, the childs insides will come out.
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
preschoolers spiritual development. Thinking that if the skin is broken, the childs insides
will come out is an example of concrete thinking in development of body image.
PTS: 1 DIF: Cognitive Level: Apply REF: 409
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 preschoolers understanding of time?
a. Has no understanding of time
b. Associates time with events
c. Can tell time on a clock
d. Uses terms like yesterday appropriately
ANS: B
In a preschoolers understanding, time has a relation with events such as Well 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 409
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 nurses 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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 409
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 nurses best interpretation of this
comment?
a. Sign of stress
b. Common at this age
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 409
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 dont want anyone taking them out. Which is the
nurses best interpretation of this?
a. Child is being overly dramatic.
b. Child has a disturbed body image.
c. Preschoolers have poorly defined body boundaries.
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 410
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 411
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Imaginary playmates are beneficial to the preschool child because they:
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 successfully 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.
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Imaginary friends do not take the place of pets or toys. Imaginary friends accomplish
what the child is still attempting.
PTS: 1 DIF: Cognitive Level: Understand REF: 412
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 composition
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 410
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?
a. 18 months
b. 24 months
c. 3 years
d. 4 years
ANS: D
At 4 years, children can understand directional phrases. Children at 18 months, 24
months, and 3 years are too young.
PTS: 1 DIF: Cognitive Level: Understand REF: 410
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 414
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 important to consider when making the selection?
a. Structured learning environment
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 412
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 satisfy 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 410
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
boogeymen are in his bedroom at night. The nurses best suggestion for coping with this
problem is to:
a. let the child sleep with his parents.
b. keep a night-light on in the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 418
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 methods to deal with the frightening
experience
b. Forcing them to confront the frightening object or experience in the presence of their
parents
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c. Using logical persuasion to explain away their fears and help them recognize how
unrealistic the fears are
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 416
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 limited.
c. By age 5 years, child can be expected to have a vocabulary of about 1000 words.
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 417
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 dysfunctional speech pattern is a normal characteristic the parents might expect?
a. Lisp
b. Stammering
c. Echolalia
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 417
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
19. During the preschool period, injury prevention efforts should emphasize:
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
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age because preschoolers are becoming more independent. Punishment may make
children scared of trying new things. Limitation of physical activities is not appropriate.
PTS: 1 DIF: Cognitive Level: Understand REF: 419-420
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. Supervise television viewing.
b. Ignore the behavior.
c. Punish the child for the behavior.
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 416-417
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. Carbonated beverage
b. 10% fruit juice
c. Low fat chocolate milk
d. Whole milk
ANS: C
Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Lowfat 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 417
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.)
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a. Think in abstract terms.
b. Follow directional commands.
c. Understand conservation of matter.
d. Use sentences of eight words.
e. Tell exaggerated stories.
f. Comprehend another persons 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 anothers
perspective.
PTS: 1 DIF: Cognitive Level: Apply REF: 413
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. Plastic telephone
b. Hand puppets
c. Jigsaw puzzle (100 pieces)
d. Farm animals and equipment
e. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 411
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.
CHAPTER 6 Growth and Development of the School-Age Child
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.
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c. There are not that many physical differences among school-age children.
d. 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, childrens
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 458
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Generally, the earliest age at which puberty begins is _____ years in girls, _____ in
boys.
a. 13; 13
b. 11; 11
c. 10; 12
d. 12; 10
ANS: C
Puberty signals the beginning of the development of secondary sex characteristics. This
begins earlier in girls than in boys. Usually a 2-year difference occurs in the age of onset.
Girls and boys do not usually begin puberty at the same age. Girls generally begin
puberty 2 years earlier than boys.
PTS: 1 DIF: Cognitive Level: Understand REF: 459
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 abstractly
b. Are capable of scientific reasoning and formal logic
c. Progress from making judgments based on what they reason to making judgments
based on what they see
d. 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 Piagets 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 460
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 within themselves.
b. They do not yet experience a sense of guilt when they misbehave.
c. They know the rules and behaviors expected of them but do not understand the reasons
behind them.
d. They no longer interpret accidents and misfortunes as punishment for misdeeds.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 460
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 that prompted it rather than just by the
consequences.
b. Rules and judgments become more absolute and authoritarian.
c. They view rule violations in an isolated context.
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 460
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. The nurse should
interpret this as:
a. a belief common at this age.
b. a belief that forms the basis for most religions.
c. suggestive of excessive family pressure.
d. 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 460
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 school-age 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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 462
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
neighborhood and school friends who have skateboards. This should be interpreted as:
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 childs
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 462
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. Individuality in play is better tolerated than at earlier ages.
b. Knowing the rules of a game gives an important sense of belonging.
c. They like to invent games, making up the rules as they go.
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 463
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Teasing can be common during the school-age years. The nurse should recognize that
which applies to teasing?
a. Can have a lasting effect on children
b. Is not a significant threat to self-concept
c. Is rarely based on anything that is concrete
d. Is usually ignored by the child who is being teased
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ANS: A
Teasing 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 462
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 between fact and fantasy.
c. They may steal because their sense of property rights is limited.
d. They may lie to meet expectations set by others 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 466-467
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 school work satisfactorily but lately has been
somewhat aggressive and stubborn in the classroom. The school nurse should recognize
this as:
a. signs of stress.
b. developmental delay.
c. physical problem causing emotional stress.
d. lack of adjustment to school environment.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 467-468
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 related to school and family.
c. They should be encouraged to hide their fears to prevent ridicule by peers.
d. Those who have numerous fears need continuous protective behavior by parents to
eliminate these fears.
ANS: B
During the school-age years, children experience a wide variety of fears, but new fears
relate predominantly to school and family. During the middle-school years, children
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become less fearful for body safety than they were as preschoolers. Parents and other
persons involved with children should discuss childrens fears with them individually or
as a group activity. Sometimes school-age children hide their fears to avoid being teased.
Hiding their fears does not end them and may lead to phobias.
PTS: 1 DIF: Cognitive Level: Analyze REF: 467-468
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. The most appropriate nursing action is to:
a. reassure the father that his child is not fat.
b. reassure the father that his child is just growing.
c. suggest a low-calorie, low-fat diet.
d. explain that this is typical of the growth pattern 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 466
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 parents tongue). Cold milk is a more suitable medium for
transport than cold water, warm salt water, or a dry, clean jar.
PTS: 1 DIF: Cognitive Level: Apply REF: 471
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.
The nurse should recognize that:
a. children in fifth grade are too young for sex education.
b. children should be discouraged from asking too many questions.
c. correct terminology should be reserved for children who are older.
d. sex can be presented as a normal part of growth and development.
ANS: D
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 471
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. Most bicycle injuries occur from a fall off the bicycle.
b. Head injuries are the major causes of bicycle-related fatalities.
c. I should replace my helmet every 5 years.
d. 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 U.S. Consumer Product Safety Commission and should
replace the helmet at least every 5 years.
PTS: 1 DIF: Cognitive Level: Apply REF: 472 | 474
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 473
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.
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b. We will discourage hobbies so our child focuses on school work.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 467
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, snacks, and 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 470
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
21. Parents of a twelve-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?
a. 8
b. 9
c. 10
d. 11
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 468
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. Animism
b. Magical thinking
c. Ability to conserve
d. Thoughts are all-powerful
ANS: C
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 460
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 463
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 childrens 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.
CHAPTER 7 Growth and Development of the Adolescent
MULTIPLE CHOICE
1. In girls, the initial indication of puberty is:
a. menarche.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 477
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. 11 1/2 years
b. 12 3/4 years
c. 13 1/2 years
d. 14 years
ANS: B
The average age of menarche is 12 years 9.5 months in North American girls, with a
normal range of 10 1/2 to 15 years. Ages 11 1/2, 13 1/2, and 14 are within the normal
range for menarche, but these are not the average ages.
PTS: 1 DIF: Cognitive Level: Remember REF: 478
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 to 12 1/2 years
b. 12 1/2 to 13 years
c. 13 to 13 1/2 years
d. 13 1/2 to 14 years
ANS: D
Concerns about pubertal delay should be considered for boys who exhibit no enlargement
of the testes or scrotal changes from 13 1/2 to 14 years. Ages 12 to 13 1/2 years is too
young for initial concern.
PTS: 1 DIF: Cognitive Level: Remember REF: 478
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 nurses 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 capacity 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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 479 | 481
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. According to Erikson, the psychosocial task of adolescence is developing:
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 Eriksons developmental stages.
PTS: 1 DIF: Cognitive Level: Understand REF: 481
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. Concrete operations
c. Conventional thought
d. Post-conventional thought
ANS: A
Cognitive thinking culminates with capacity for abstract thinking. This stage, the period
of formal operations, is Piagets fourth and last stage. Concrete operations usually occur
between ages 7 and 11 years. Conventional and post-conventional thought refer to
Kohlbergs stages of moral development.
PTS: 1 DIF: Cognitive Level: Understand REF: 482
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 logical order
c. Ability to see things from the point of view of another
d. Progress from making judgments based on what they see to making judgments based
on what they reason
ANS: A
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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.
PTS: 1 DIF: Cognitive Level: Remember REF: 482
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 adolescents.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 483
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. The
nurses response should be based on knowledge that:
a. this indicates the adolescent is homosexual.
b. this indicates the adolescent will become homosexual as an adult.
c. the adolescent should be referred for psychotherapy.
d. 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 societys reaction to the behavior. The nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 486
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
maintained unless a life-threatening situation arises. This practice is:
a. not appropriate in a school setting.
b. never appropriate because adolescents are minors.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 487
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. This is normal because of increase in body mass.
b. This is abnormal and suggestive of future obesity.
c. His caloric intake would have to be excessive.
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 478-479
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 feeling of fatigue
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 490
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. The most common cause of death in the adolescent age group involves:
a. drownings.
b. firearms.
c. drug overdoses.
d. motor vehicles.
ANS: D
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 487
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. The nurse should explain that
this occurs in adolescents because of:
a. growth of the extremities and neck precedes growth in other areas.
b. growth is in the trunk and chest.
c. the hip and chest breadth increases.
d. 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 long-legged, gawky appearance of early
adolescent children. The growth spurt occurs earlier in girls than in boys.
PTS: 1 DIF: Cognitive Level: Apply REF: 478
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. The hormone
that is responsible for the growth of beard, mustache, and body hair in the male is:
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 481
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. The nurse interprets this
behavior as:
a. requiring a referral to a mental health counselor.
b. requiring some further lab testing.
c. normal behavior.
d. related to feelings of depression.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 482
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. Laissez-faire
b. Authoritative
c. Disciplinarian
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 483
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. Which should the nurse
recommend?
a. One dose of the varicella vaccination
b. Two doses of the varicella vaccination 4 weeks apart
c. One dose of the varicella immune globulin
d. No vaccinationsthe 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 489
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 488-489
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 conditions? (Select all that apply.)
a. Phototoxic reactions
b. Increased number of moles
c. Premature aging
d. Striae
e. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 492
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. Hearing
d. Cholesterol
e. Scoliosis
ANS: B, C, E
The school nurse should perform vision, hearing, and scoliosis screening tests according
to the school districts required schedule. Glucose and cholesterol screening would be
performed in the medical clinic setting.
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PTS: 1 DIF: Cognitive Level: Apply REF: 491
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 489
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
ESSAY
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.
CHAPTER 8 Atraumatic Care of Children and Families
MULTIPLE CHOICE
1. The best site for the nurse to use when assessing the pulse rate on a 12-month-old
infant is:
a
.
Brachial pulse
b
.
Apical pulse
c
.
Radial pulse
d
.
Femoral pulse
ANS: B
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Apical pulses are advised for children under age 5 years.
DIF: Cognitive Level: Application REF: 486 OBJ: 11
TOP: Physical Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. When the nurse starts to administer a medication to a 2-month-old child, the nurse
discovers there is no ID bracelet on the child. The nurse should:
a
.
Give the medication after confirming the childs name
from the foot of the crib.
b
.
Ask the charge nurse to give the medicine.
c
.
Confirm the identity with the charge nurse, make a new
bracelet, and give the medicine.
d
.
Delay the medication until the admissions office can
supply a new ID bracelet.
ANS: C
After confirmation of the childs identity with the charge nurse and making a new bracelet,
the medication can be safely given. All patients should be identified before treatment.
DIF: Cognitive Level: Analysis REF: 481 OBJ: 2
TOP: ID Bracelets KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. The nurse instructed an adolescent female about collecting a clean-catch urine
specimen. The nurse determined the adolescent understood the instructions when she
stated:
a
.
I should wash my perineum with soap and water, then
begin to urinate.
b
.
I clean the perineum from front to back with an antiseptic
wipe before I urinate.
c
.
Ill collect the first stream of urine in a sterile container.
d
.
I will discard the first void and collect a freshly voided
specimen 30 minutes later.
ANS: B
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To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from
front to back.
DIF: Cognitive Level: Analysis REF: 493 OBJ: N/A
TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
4. The strategy the nurse might use when administering oral medications to a young child
who is reluctant to take it is:
a
.
Mix the medication with chocolate milk.
b
.
Tell the child that the medication is candy.
c
.
Give the medication quickly if the child is crying.
d
.
Offer the child fruit juice after the medication is
swallowed.
ANS: D
The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the
medication has been swallowed. Medications should not be mixed with important
nutrients such as milk since the child may develop a distaste for the food.
DIF: Cognitive Level: Application REF: 498 OBJ: 5
TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A parent tells the nurse, Im not sure how to give this medicine to my infant. The nurse
would teach the parent to best administer an oral suspension by:
a
.
Pouring the medication into a small cup and allowing the
infant to drink it
b
.
Placing the medication in a nipple and having the infant
suck the nipple
c
.
Using an oral syringe and placing the medication in the
side of the infants mouth
d
.
Administering the medication with a dropper onto the
back of the infants tongue
ANS: C
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An oral syringe is a useful device for measuring small quantities of medications for
infants. The syringe is placed midway back at the side of the mouth.
DIF: Cognitive Level: Application REF: 500 OBJ: 5
TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. Garamycin ear drops are prescribed for a 4-year-old child. To administer the ear drops
the nurse would pull the auricle:
a
.
Up and back
b
.
Down and back
c
.
Up and out
d
.
Down and out
ANS: A
For children 3 years of age and older, the auricle is gently pulled upward and backward to
straighten the canal.
DIF: Cognitive Level: Application REF: 501 OBJ: 13
TOP: Administering Ear Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. The nurse explains that the tympanic thermometer is more accurate because:
a
.
The thermometer probe is blunt and wide.
b
.
It takes a brief time to register.
c
.
The tympanic membrane shares circulation with the
hypothalamus.
d
.
The tympanic membrane and the brain have the same
temperature.
ANS: C
The accuracy of the tympanic thermometer is attributable to the fact that the tympanic
membrane and the hypothalamus share the same circulation.
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DIF: Cognitive Level: Application REF: 489 OBJ: 8
TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. The intervention that would be correct when a nurse is administering a gastrostomy
feeding by gravity is:
a
.
Discard the residual and increase the volume of feeding
by the amount of residual.
b
.
Flush the gastrostomy tube with 2 to 4 oz of water before
the feeding.
c
.
Refill the syringe with formula after it has completely
emptied.
d
.
Position the child on the right side after a feeding.
ANS: D
To prevent regurgitation and aspiration, the child is placed in the Fowlers position or on
its right side to promote gastric emptying after a gastrostomy tube feeding.
DIF: Cognitive Level: Application REF: 511 OBJ: N/A
TOP: Enteral Feedings KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
9. The restraint that is most appropriate for the insertion of an intravenous line in a scalp
vein of an infant is the:
a
.
Mummy
b
.
Clove hitch
c
.
Jacket
d
.
Elbow
ANS: A
A mummy restraint would be used to restrain an infant for insertion of an intravenous line
in a scalp vein.
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DIF: Cognitive Level: Comprehension REF: 483 OBJ: 2
TOP: Restraining the Infant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
10. A child who has a continuous intravenous infusion should be assessed every:
a
.
Hour
b
.
Two hours
c
.
Three hours
d
.
Four hours
ANS: A
The nurse must assess hourly an intravenous infusion for complications, such as
inflammation and infiltration.
DIF: Cognitive Level: Knowledge REF: 503 OBJ: 6
TOP: Administering Parenteral Medications
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Risk Reduction
11. The prescription for a 4-month-old is: penicillin G 150,000 units IM bid. The drug is
supplied as a unit dose of 600,000 units in a 5-ml vial. The nurse should give the dose as:
a
.
1 ml
b
.
1.4 ml
c
.
1.6 ml
d
.
1.8 ml
ANS: B
This dose would have to be given in divided doses as only 1 ml should be injected in one
site on an infant.
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DIF: Cognitive Level: Application REF: 498 OBJ: 6
TOP: Administering Injections KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. When suctioning a tracheostomy, the nurse will:
a
.
Suction for a period of 2 to 3 breaths.
b
.
Clear the catheter with water after suctioning for reuse.
c
.
Apply suction for no more than 15 seconds.
d
.
Establish a regular schedule for suctioning.
ANS: C
Suctioning should be limited to 15 seconds.
DIF: Cognitive Level: Knowledge REF: 510 OBJ: 7
TOP: Respiration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. The emergency action for airway obstruction in the infant is to give:
a
.
6 to 10 midsternal thrusts
b
.
5 back blows followed by 5 chest thrusts
c
.
5 chest thrusts followed by 5 back blows
d
.
Abdominal thrusts until the object is expelled
ANS: B
Five back blows followed by 5 chest thrusts is the appropriate intervention for airway
obstruction in the infant.
DIF: Cognitive Level: Knowledge REF: 514 OBJ: N/A
TOP: Management of Airway Obstruction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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14. When the 4-year-old asks tearfully if the IM injection will hurt, the nurses most
effective response is:
a
.
No. It is over before you know it
b
.
Yes. It will sting a little.
c
.
No. Would you like to see the syringe?
d
.
Yes. Your mom and I are going to hold you to help you
be still.
ANS: B
Truthful answers will give a child a realistic expectation and help establish trust in the
nurse.
DIF: Cognitive Level: Implementation REF: 503 OBJ: 6
TOP: Preparation for an IM Injection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15. The nurse selects the best site for giving an intramuscular injection to a 15-month-old
child, which is the:
a
.
Ventrogluteal muscle
b
.
Dorsogluteal muscle
c
.
Deltoid muscle
d
.
Vastus lateralis muscle
ANS: D
The vastus lateralis muscle is free of major blood vessels and nerves and can be used in
children of any age.
DIF: Cognitive Level: Application REF: 502 OBJ: 14
TOP: Administering Injections KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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16. The nurse explains that the factor that affects the infants physiological response to
medications is:
a
.
Faster metabolism in the liver
b
.
Slower intestinal transit
c
.
Immature kidney function
d
.
Increased secretion of hydrochloric acid
ANS: C
Immature kidney function prevents effective excretion of drugs from the body in infants
less than 1 year of age.
DIF: Cognitive Level: Analysis REF: 495 OBJ: 5
TOP: Physiological Responses to Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
17. After topical administration of hydrocortisone cream to the buttocks and abdomen of
an infant, the nurse should:
a
.
Diaper the infant snugly with a disposable diaper.
b
.
Cover the area with a transparent dressing.
c
.
Apply a cloth diaper.
d
.
Place the infant on a plastic pad, undiapered.
ANS: C
Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the
child should be left undiapered on a cloth pad.
DIF: Cognitive Level: Analysis REF: 495 OBJ: 5
TOP: Rapid Absorption of Drug KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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18. On entering the hospital room, the nurse takes note of all the options below. The
observation that would indicate a need for the parents to receive safety education to
prevent unintentional injury is:
a
.
The blanket is not tucked into the mattress.
b
.
Diapers and wipes are stacked at the foot of the crib.
c
.
The crib side is locked in the up position.
d
.
Pillows are stacked on the bedside table.
ANS: B
Disposable diapers and supplies must be kept out of the infants reach to prevent
accidental suffocation.
DIF: Cognitive Level: Analysis REF: 483 OBJ: 2
TOP: Essential Safety Measures KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
19. The nurse prepares a 9-year-old child for a lumbar puncture by explaining that the
position for this procedure is:
a
.
On your stomach with your head turned to the side.
b
.
On your side, keeping the legs bent and the head arched
back.
c
.
On your back with your legs extended straight out.
d
.
On your side with the knees bent and the head close to
the knees.
ANS: D
The child is positioned on its side with the knees flexed, and the head is brought down
close to the flexed knees.
DIF: Cognitive Level: Application REF: 494 OBJ: 4
TOP: Collecting Specimens-Lumbar Puncture
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. The nurse is caring for a 4-year-old child. When reviewing yesterdays intake and
output record, the nurse would expect the childs daily urinary output to be approximately:
a
.
400 to 500 ml
b
.
500 to 600 ml
c
.
600 to 700 ml
d
.
700 to 1000 ml
ANS: C
The average daily excretion of urine for a 4-year-old child is 600 to 700 ml.
DIF: Cognitive Level: Knowledge REF: 506 OBJ: 12
TOP: Collecting Specimens-Urine Output
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. The nurse
would record the infants urine output as:
a
.
47 ml
b
.
44.5 ml
c
.
43.5 ml
d
.
40.5 ml
ANS: B
Urine output is determined by calculating the difference in weight between the wet diaper
and a dry diaper. Key Point: One gram is equivalent to one milliliter of output.
47 2.5 = 44.5 grams = 44.5 ml of urine.
DIF: Cognitive Level: Application REF: 507 OBJ: 12
TOP: Collecting Specimens-Urine Output
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KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. The nurse clarifies that the informed consent for a minor guarantees that the parent or
legal guardian understands:
Select all that apply.
a
.
Purpose of the procedure
b
.
Associated risks
c
.
No suit can be brought for damages
d
.
The document must be signed and witnessed
e
.
Information given
ANS: A, B, D, E
The informed consent establishes that the patient, parent, or legal guardian understands
the purpose and risks of the procedure. It also establishes that the patient, parent, or legal
guardian understands what they have been told; the document should be signed and
witnessed.
CHAPTER 9 Health Supervision
MULTIPLE CHOICE
1. Which child would have the most difficulty in coping with separation from parents
because of hospitalization?
a
.
The 3-month-old child
b
.
The 16-month-old child
c
.
The 4-year-old child
d
.
The 7-year-old child
ANS: B
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Separation anxiety occurs after age 6 months and is most pronounced in the toddler.
DIF: Cognitive Level: Comprehension REF: 466-467 OBJ: 2
TOP: Separation Anxiety KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
2. A 2-year-old child has been crying constantly for his mother since he was hospitalized
3 days ago. The nurse understands that this behavior suggests:
a
.
The toddler feels abandoned by his mother.
b
.
The child still has not adjusted to his hospitalization.
c
.
The child is not separated from his mother often.
d
.
A poor mother-child bond exists.
ANS: A
Unless toddlers are extremely ill, their grief and sense of abandonment during
hospitalization are obvious.
DIF: Cognitive Level: Analysis REF: 465-466 OBJ: 2
TOP: Separation Anxiety KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. The statement that best corresponds to a preschoolers understanding of hospitalization
is:
a
.
A germ made me get sick.
b
.
I got sick because I was mad at my brother.
c
.
My tonsils are sick and they have to come out.
d
.
I have a cast because I broke my leg.
ANS: B
The preschooler may feel guilty, particularly if an accident happens as a result of
mischief on his or her part.
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DIF: Cognitive Level: Application REF: 476 OBJ: 6
TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
4. The parents of a hospitalized toddler are upset because she seems more interested in
her toys when they come to visit her. The toddler is most likely in which stage of
separation anxiety?
a
.
Protest
b
.
Despair
c
.
Denial
d
.
Attachment
ANS: C
In the stage of denial or detachment, the child appears to deny the need for the parents
and becomes uninterested in their visits.
DIF: Cognitive Level: Comprehension REF: 465-466 OBJ: 2
TOP: Separation Anxiety KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
5. The nurse must make a room assignment for a 16-year-old teenager with cystic
fibrosis. An optimal roommate might be:
a
.
A 4-year-old child who had an appendectomy
b
.
A 10-year-old child with sickle cell disease in vasoocclusive crisis
c
.
A 15-year-old teenager with type 1 diabetes mellitus
d
.
To assign the adolescent to a private room
ANS: C
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Adolescents usually do better in rooms with one or more roommates than in single
rooms. The adolescent would do best with a roommate who is closest to his or her age
and also lives with a chronic illness.
DIF: Cognitive Level: Application REF: 477 OBJ: 8
TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. The parents of a hospitalized 9-month-old infant ask if their preschool child may visit
his younger sibling. The nurse understands that:
a
.
Most facilities do not allow visitors under age 12 years
for infection control purposes.
b
.
Seeing his younger sibling would probably frighten the
preschooler and thus should be avoided.
c
.
The sibling could view the infant from the doorway but
not enter the room to prevent the spread of
microorganisms.
d
.
The preschooler needs to visit his infant sister to reassure
himself that she is all right.
ANS: D
Siblings are affected by a childs hospitalization. Their ability to cope is influenced by
their age, experience, and intactness of the family.
DIF: Cognitive Level: Analysis REF: 474 OBJ: 3
TOP: Siblings-Parents Reaction to Hospitalization
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
7. A hospitalized toddler was drinking from a cup at home, but now refuses to drink from
anything except his favorite bottle. This is because the toddler is:
a
.
Dealing with the anxiety of hospitalization by regressing
b
.
Demonstrating attention-seeking behaviors because of an
overabundance of attention in the hospital
c
.
Attempting to refocus the attention of the adults around
him to avoid further painful procedures
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d
.
Exhibiting normal behavior for his age, as children often
stop new behaviors after they feel they have mastered
them
ANS: A
Hospitalization is frustrating for toddlers. They show their displeasure when illness
restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from
a cup to refuse it in the hospital.
DIF: Cognitive Level: Comprehension REF: 468 OBJ: 4
TOP: Regression KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
8. A nurse encourages a school-age child to draw a picture after a painful procedure. The
best rationale for this intervention is that the nurse is:
a
.
Attempting to reestablish rapport
b
.
Providing a way for the child to express his feelings
c
.
Encouraging quiet play
d
.
Distracting the child from thinking about the pain
ANS: B
Following treatments, the nurse should encourage children to draw and talk about their
drawings or to act out their feelings through puppet play.
DIF: Cognitive Level: Comprehension REF: 490 OBJ: 7
TOP: The Hospitalized School-Age Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
9. The nurse suggests that the best time for parents to begin to prepare a 5-year-old for
surgery and hospitalization is:
a
.
As soon as the surgery is scheduled
b
.
About 2 weeks before surgery
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c
.
About 4 days before surgery
d
.
On the night before admission to the hospital
ANS: C
Parents should prepare children for procedures and hospitalization a few days in advance.
DIF: Cognitive Level: Application REF: 471 OBJ: 4, 6
TOP: The Nurses Role in Hospital Admission-Preparing the Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
10. The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around
12:00 PM. The next morning, the child asks the nurse, When is my mommy coming? The
best response for the nurse to make is:
a
.
Your mommy will be here around noon.
b
.
Your mommy will be here when you have lunch.
c
.
Mommy will be here very soon.
d
.
Your mommy is coming in 4 hours.
ANS: B
The toddler and preschooler do not understand time yet. They understand time
relationships through activities in their experience, such as naptime and mealtimes.
DIF: Cognitive Level: Application REF: 476 OBJ: 6
TOP: The Hospitalized Toddler/Preschooler
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
11. A 13-year-old girl has been hospitalized for the past week. When discussing the girls
feelings about her illness, the nurse would expect the girl to express the most concern
about:
a
.
Invasive procedures
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b
.
Loss of control
c
.
Appearance
d
.
Separation from her boyfriend
ANS: C
Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image.
DIF: Cognitive Level: Comprehension REF: 477 OBJ: 8
TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
12. The nurse notices that the mother of a child with cerebral palsy corrects and redoes
many of the things the nurse does for her child. The most appropriate response to this
mother would be:
a
.
Would you like to do all of your childs care?
b
.
Im doing the very best job that I can with your child.
c
.
Why dont you go have a cup of coffee. You are going to
be exhausted if you dont take a break.
d
.
Id be happy if you would share with me some of the
special things you do for your child.
ANS: D
The person who cares daily for the child with a chronic illness can provide information
that will best guarantee continuity of care between the home and the hospital.
DIF: Cognitive Level: Application REF: 472 OBJ: 4
TOP: The Parents Reaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
13. The mother of a hospitalized toddler states, He cries when I visit. Maybe I should just
stay away. The nurses best response would be:
a
.
Perhaps you are right. He only gets upset when you have
to leave.
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b
.
It is important that you are here. This is a common
reaction in children when they are separated from their
parents.
c
.
It might be easier for your child if you would stay with
him, but this decision is up to you.
d
.
We take good care of him and he seems fine when you
are not here.
ANS: B
During the second stage of separation anxiety (despair), the child is quiet, is not crying,
and is sad and depressed. The child will revert to protest when the parent arrives for a
visit.
DIF: Cognitive Level: Application REF: 466 OBJ: 3
TOP: Separation Anxiety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
14. The nurse, preparing to collect an admission history from parents who have recently
immigrated from Russia, would keep in mind that:
a
.
Eye-to-eye contact is considered disrespectful.
b
.
Touching the childs head means the nurse is superior.
c
.
Smiling is inappropriate in a serious situation.
d
.
Staring is a sign of the nurses rudeness.
ANS: C
In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.
DIF: Cognitive Level: Analysis REF: 468 OBJ: 4
TOP: Fostering Intercultural Communication
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
15. The nursing action that would facilitate rapport with a child and the childs parents
during the admission process is:
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a
.
Direct the parents to undress the child.
b
.
Answer questions in a calm and matter-of-fact way.
c
.
Perform assessments and ask questions as quickly as
possible.
d
.
Express concern about the seriousness of the childs
condition.
ANS: B
The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained
regardless of the childs condition.
DIF: Cognitive Level: Application REF: 474 OBJ: 4
TOP: Nurses Role in Hospital Admission
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
16. When a 2-year-old returns to her hospital room following a diagnostic procedure, her
parents are not available and the child is crying loudly. The technique that is most
appropriate to alleviate the childs distress is:
a
.
Rock the child gently to sleep.
b
.
Play with the child using pop-up toys.
c
.
Role play with the child to act out her feelings.
d
.
Ask the child to draw a picture about her feelings.
ANS: B
Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with
pop-up toys may help reduce anxiety and pain.
DIF: Cognitive Level: Analysis REF: 474 OBJ: 10
TOP: The Hospitalized Toddler KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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17. A 4-year-old begins to cry when his mother tells him it is time for his operation. The
nurse understands this is an expected reaction because the preschooler is particularly
fearful of:
a
.
Loss of control
b
.
Restricted mobility
c
.
Unfamiliar routines
d
.
Invasive procedures
ANS: D
The preschool-age child is afraid of bodily harm, particularly invasive procedures.
DIF: Cognitive Level: Knowledge REF: 476 OBJ: 6
TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
18. The nurse determines a parent understands a hospitalized toddlers need for
transitional objects when the parent states:
a
.
This stuffed animal makes him feel secure.
b
.
He insisted on bringing this dirty old blanket with him.
c
.
Im going to buy him a big stuffed animal from the gift
shop.
d
.
Id like to get him some toys from the playroom.
ANS: A
The use of a transitional object such as a blanket or a favorite toy promotes security.
DIF: Cognitive Level: Comprehension REF: 475 OBJ: 10
TOP: The Hospitalized Toddler KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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19. An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat
a fractured femur. In planning care for the child, the nurse realizes immobilization in this
age group can generate feelings of:
a
.
Loss of control
b
.
Altered body image
c
.
Shame and guilt
d
.
Fear of bodily harm
ANS: A
Forced dependency in the hospital, such as immobilization, can result in a feeling of loss
of control and loss of security.
DIF: Cognitive Level: Analysis REF: 477 OBJ: 10
TOP: The Hospitalized School-Age Child
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
20. The nurse explains the use of fentanyl has the advantages of:
a
.
Being specifically designed for children
b
.
Rapid onset
c
.
Nonaddicting
d
.
Long duration
ANS: B
Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.
DIF: Cognitive Level: Application REF: 467 OBJ: 5
TOP: Fentanyl KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
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1. The nurse suggests to parents that they avail themselves of the outpatient surgical
center for their childs upcoming surgery because the surgical center has the advantages
of:
Select all that apply.
a
.
Lower cost
b
.
Less incidence of nosocomial infections
c
.
Reduction of parent-child separation
d
.
Recuperation at home
e
.
Decreased emotional impact of illness
ANS: A, B, C, D, E
All options listed are advantages of outpatient services.
DIF: Cognitive Level: Application REF: 463 OBJ: 4
TOP: Use of Outpatient Facilities KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
2. The nurse understands that no matter the reason for the young child being hospitalized,
the basic fears are:
Select all that apply.
a
.
Separation
b
.
Permanent scarring
c
.
Pain
d
.
Cost
e
.
Body intrusion
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ANS: A, C, E
Small children all share the same basic fears relative to hospitalization, which are
separation from family, pain, and body intrusion or mutilation.
DIF: Cognitive Level: Comprehension REF: 465 OBJ: 2
TOP: Basic Fear KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. The nurse taking a developmental history will include information relative to:
Select all that apply.
a
.
Previous experience with hospitalization
b
.
Cultural needs
c
.
History of illness
d
.
Allergies
e
.
Childs nickname
ANS: A, B, E
The developmental history has information about the child and the childs developmental
and cultural needs and personal preferences. The information relative to history of illness
or allergies would be covered in the medical history.
DIF: Cognitive Level: Application REF: 475 OBJ: 4
TOP: Developmental History KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
COMPLETION
1. When the preschooler who is hospitalized for surgery to correct a poorly healed
fracture says, My doctor is going to unscrew my bent arm and screw on a new one, the
nurse should ____________________ this misconception.
ANS: correct
CHAPTER 10 Health Assessment of Children
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.
Introduce self.
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b.
Make family comfortable.
c.
Explain purpose of interview.
d.
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 nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 87
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
childs illness?
a.
Be sympathetic.
b.
Use direct questions.
c.
Use open-ended questions.
d.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 88
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.
Using silence
b.
Using clichs
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c.
Directing the focus
d.
Defining the problem
ANS: B
Using stereotyped comments or clichs 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 90
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 childs physical condition
b.
Presence or absence of the childs parent
c.
The childs developmental level
d.
The childs nonverbal behaviors
ANS: C
The nurse must be aware of the childs developmental stage to engage in effective
communication. The use of both verbal and nonverbal communication should be
appropriate to the developmental level. Although the childs 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
childs developmental level.
PTS: 1 DIF: Cognitive Level: Understand REF: 91
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 toddlers name while picking him or her up.
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c
.
Call the toddlers name and say, Im your nurse.
d
.
Stand by the toddler, addressing him or her by
name.
ANS: A
It is important that the nurse assume a position at the childs 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,
Im your nurse. If a positive response is desired, the nurse should assume the childs level
when speaking if possible.
PTS: 1 DIF: Cognitive Level: Apply REF: 91
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 90-91
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.
Focus communication on child.
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b.
Explain experiences of others to child.
c.
Use easy analogies when possible.
d.
Assure child that communication is private.
ANS: A
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 91
TOP:Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
8. The nurses approach when introducing hospital equipment to a preschooler should be
based on which principle?
a
.
The child may think the equipment is alive.
b
.
The child is too young to understand what the
equipment does.
c
.
Explaining the equipment will only increase the childs
fear.
d
.
One brief explanation will be enough to reduce the
childs fear.
ANS: A
Young children attribute human characteristics to inanimate objects. They often fear that
the objects may jump, bite, cut, or pinch all by themselves without human direction.
Equipment should be kept out of sight until needed. The child should be given simple
concrete explanations about what the equipment does and how it will feel to the child.
Simple, concrete explanations will help alleviate the childs fear. The preschooler will
need repeated explanations as reassurance.
PTS: 1 DIF: Cognitive Level: Analyze REF: 91
TOP:Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
9. A nurse is assigned to four children of different ages. In which age group should the
nurse understand that body integrity is a concern?
a.
Toddler
b.
Preschooler
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c.
School-age child
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 92
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
10. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most
appropriate nursing action is to:
a.
ask her why she wants to know.
b.
determine why she is so anxious.
c.
explain in simple terms how it works.
d.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 91-92
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
11. When the nurse interviews an adolescent, which is especially important?
a
.
Focus the discussion on the peer group.
b
.
Allow an opportunity to express feelings.
c
.
Emphasize that confidentiality will always be
maintained.
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d
.
Use the same type of language as the adolescent.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 92
TOP:Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
12. The nurse is having difficulty communicating with a hospitalized 6-year-old child.
What technique might be most helpful?
a
.
Suggest that the child keep a diary.
b
.
Suggest that the parent read fairy tales to the child.
c
.
Ask the parent if the child is always
uncommunicative.
d
.
Ask the child to draw a picture.
ANS: D
Drawing is one of the most valuable forms of communication. Childrens drawings tell a
great deal about them because they are projections of the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 94
TOP:Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
13. 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. This should be interpreted as:
a.
inappropriate, because of childs age.
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 92
TOP:Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
14. The nurse must assess 10-month-old infant. The infant is sitting on the fathers 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 examination
table.
c
.
Undress the infant while he is still sitting on his
fathers 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
fathers lap. The nurse should have the father undress the child as needed for the
examination.
PTS: 1 DIF: Cognitive Level: Apply REF: 94
TOP:Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
15. The nurse is taking a health history on an adolescent. Which best describes how the
chief complaint should be determined?
a
.
Ask for detailed listing of symptoms.
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b
.
Ask adolescent, Why did you come here today?
c
.
Use what adolescent says to determine, in correct
medical terminology, what the problem is.
d
.
Interview parent away from adolescent to determine
chief complaint.
ANS: B
The chief complaint is the specific reason for the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 92
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
16. 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 childs health, not to the current problem. The chief complaint is the specific
reason for the childs 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 96
TOP:Integrated Process: Communication and Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
17. The nurse is interviewing the mother of an infant. She reports, I had a difficult
delivery, and my baby was born prematurely. This information should be recorded under
which of the following headings?
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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 childs health,
not to the current problem. The mothers 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 childs 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 premature birth.
Sequelae such as pulmonary dysfunction would be included.
PTS: 1 DIF: Cognitive Level: Understand REF: 96
TOP:Integrated Process: Communication and Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
18. Which is most important to document about immunizations in the childs health
history?
a.
Dosage of immunizations received
b.
Occurrence of any reaction after an immunization
c.
The exact date the immunizations were received
d.
Practitioner who administered the immunizations
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 97
TOP:Integrated Process: Communication and Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
19. When interviewing the mother of a 3-year-old child, the nurse asks about
developmental milestones such as the age of walking without assistance. This should be
considered:
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a
.
unnecessary information because child is age 3
years.
b
.
an important part of the family history.
c
.
an important part of the childs past history.
d
.
an important part of the childs review of systems.
ANS: C
Information about the attainment of developmental milestones is important to obtain. It
provides data about the childs growth and development that should be included in the
past history. Developmental milestones provide important information about the childs
physical, social, and neurologic health and should be included in the history for a 3-yearold 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 97
TOP:Integrated Process: Communication and Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
20. The nurse is taking a sexual history on an adolescent girl. Which is the best way to
determine whether she is sexually active?
a
.
Ask her, Are you sexually active?
b
.
Ask her, Are you having sex with anyone?
c
.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 98
TOP:Integrated Process: Nursing Process: Assessment
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MSC:Area of Client Needs: Health Promotion and Maintenance
21. When doing a nutritional assessment on a Hispanic family, the nurse learns that their
diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 99 | 102
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
22. Which following parameters correlate best with measurements of the bodys total
protein stores?
a.
Height
b.
Weight
c.
Skin-fold thickness
d.
Upper arm circumference
ANS: D
Upper arm circumference is correlated with measurements of total muscle mass. Muscle
serves as the bodys major protein reserve and is considered an index of the bodys protein
stores. Height is reflective of past nutritional status. Weight is indicative of current
nutritional status. Skin-fold thickness is a measurement of the bodys fat content.
PTS: 1 DIF: Cognitive Level: Understand REF: 102
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
23. A nurse is preparing to perform a physical assessment on a toddler. Which approach
should the nurse use for this child?
a.
Always proceed in a head-to-toe direction.
b.
Perform traumatic procedures first.
c.
Use minimal physical contact initially.
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d.
Demonstrate use of equipment.
ANS: C
Parents can remove clothing, and the child can remain on the parents lap. The nurse
should use minimal physical contact initially to gain the childs cooperation. The head-totoe 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 106
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
24. 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. This action
should be considered:
a
.
appropriate because of childs age.
b
.
appropriate because mother would be uncomfortable
making decisions for child.
c
.
inappropriate because of childs 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 childs need for privacy. Although
the question was appropriate for the childs age, the mother is responsible for making
decisions for the child. It is appropriate because of the childs age. During the
examination, the nurse must respect the childs privacy. The child should help determine
who is present during the examination.
PTS: 1 DIF: Cognitive Level: Apply REF: 107
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
25. 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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 108-109
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
26. The nurse is using the NCHS 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 NCHS
growth chart is used for non-Caucasian ethnic groups.
d
.
The NCHS charts are accurate for U.S. AfricanAmerican children.
ANS: D
The NCHS growth charts can serve as reference guides for all racial or ethnic groups.
U.S. African-American 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 107
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
27. 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 skin-fold thickness, which is an indicator of body fat
content. Stadiometers are used to measure height. Cloth tape measures should not be used
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because they can stretch. Paper or metal tape measures can be used for recumbent lengths
and other body measurements that must be made.
PTS: 1 DIF: Cognitive Level: Understand REF: 111
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
28. The nurse is using calipers to measure skin-fold thickness over the triceps muscle in a
school-age child. What is the purpose of doing this?
a.
To measure body fat
b.
To measure muscle mass
c.
To determine arm circumference
d.
To determine accuracy of weight measurement
ANS: A
Measurement of skin-fold 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 111
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
29. 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.
2 1/2 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 2 1/2 to 3 years.
PTS: 1 DIF: Cognitive Level: Remember REF: 111
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
30. Which would be best for the nurse to use when determining the temperature of a
preterm infant under a radiant heater?
a.
Axillary sensor
b.
Tympanic membrane sensor
c.
Rectal mercury glass thermometer
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d.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 112
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
31. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 115
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
32. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 115
TOP:Integrated Process: Nursing Process: Assessment
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MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
33. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 119
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
34. The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of
hands. This should be interpreted as:
a.
normal.
b.
erythema.
c.
jaundice.
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 119
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
35. When palpating the childs cervical lymph nodes, the nurse notes that they are tender,
enlarged, and warm. What is the best explanation for this?
a.
Some form of cancer
b.
Local scalp infection common in children
c.
Infection or inflammation distal to the site
d.
Infection or inflammation close to the site
ANS: D
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 120
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
36. During a routine health assessment, the nurse notes that an 8-month-old infant has
significant head lag. Which is the nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 120
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
37. The nurse has just started assessing a young child who is febrile and appears very ill.
There is hyperextension of the childs 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
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Hyperextension of the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 121
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
38. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 121
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
39. During a funduscopic examination of a school-age child, the nurse notes a brilliant,
uniform red reflex in both eyes. The nurse should recognize that this is a(n):
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 122
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
40. Parents of a newborn are concerned because the infants eyes often look crossed when
the infant is looking at an object. The nurses response is that this is normal based on the
knowledge that binocularity is normally present by what age?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 122
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
41. A nurse is preparing to test a school-age childs 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 (Denverletter
E; Allenpictures) 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 123
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
42. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 123
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TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
43. The nurse is testing an infants visual acuity. By what age should the infant be able to
fix on and follow a target?
a.
1 month
b.
1 to 2 months
c.
3 to 4 months
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 122
TOP:Integrated Process: Nursing Process: Problem Identification
MSC:Area of Client Needs: Health Promotion and Maintenance
44. The appropriate placement of a tongue blade for assessment of the mouth and throat
is:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 128
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
45. An appropriate screening test for hearing that can be administered by the nurse to a 5year-old child is:
a.
the Rinne test.
b.
the Weber test.
c.
conventional audiometry.
d.
eliciting the startle reflex.
ANS: C
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 127
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
46. 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.
Vesicular
b.
Bronchial
c.
Adventitious
d.
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 131
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
47. A nurse is assessing a patient admitted for an asthma exacerbation. Which breath
sounds does the nurse expect to assess?
a.
Rubs
b.
Rattles
c.
Wheezes
d.
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 132
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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48. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 132
TOP:Integrated Process: Teaching/Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
49. The nurse must assess a childs capillary refill time. This can be accomplished by:
a.
inspecting the chest.
b.
auscultating the heart.
c.
palpating the apical pulse.
d.
palpating the skin to produce a slight blanching.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 133
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
50. A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart
sound does the nurse expect to assess?
a.
S3
b.
S4
c.
Murmur
d.
Physiologic splitting
ANS: C
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Murmurs are the sounds that are produced in the heart chambers or major arteries from
the back-and-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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 134
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
51. The nurse has determined the rate of both the childs radial pulse and heart. When
comparing the two rates, the nurse should expect that normally they:
a.
are the same.
b.
differ, with heart rate faster.
c.
differ, with radial pulse faster.
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 134
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
52. 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.
Up and back
b.
Down and back
c.
Straight back
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 126
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
53. The nurse has a 2-year-old boy sit in tailor position during palpation for the testes.
What is the rationale for this position?
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a.
It prevents cremasteric reflex.
b.
Undescended testes can be palpated.
c.
This tests the child for an inguinal hernia.
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 138
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
54. During examination of a toddlers extremities, the nurse notes that the child is
bowlegged. The nurse should recognize that this finding is:
a
.
abnormal and requires further investigation.
b
.
abnormal unless it occurs in conjunction with knockknee.
c
.
normal if the condition is unilateral or asymmetric.
d
.
normal because the lower back and leg muscles 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 AfricanAmerican children.
PTS: 1 DIF: Cognitive Level: Understand REF: 139
TOP:Integrated Process: Nursing Process: Problem Identification
MSC:Area of Client Needs: Health Promotion and Maintenance
55. At about what age does the Babinski sign disappear?
a.
4 months
b.
6 months
c.
1 year
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 139
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
56. A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her
to do the finger-to-nose test. The nurse is testing for:
a.
deep tendon reflexes.
b.
cerebellar function.
c.
sensory discrimination.
d.
ability to follow directions.
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 childs ability to follow
directions, it is used primarily for cerebellar function.
PTS: 1 DIF: Cognitive Level: Apply REF: 140
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
57. Which figure depicts a nurse performing a test for the triceps reflex?
a.
c.
b.
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 reflex (slightly above the antecubital space) patellar (knee) and Achilles
(behind the foot).
PTS: 1 DIF: Cognitive Level: Analyze REF: 140
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 appropriatesize blood pressure cuff? (Select all that apply.)
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 116
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 95
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.
Delayed sexual development
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b.
Edema
c.
Pruritus
d.
Jaundice
e.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 104
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 nonEnglish 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 90
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
ESSAY
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1. Place in correct sequence, the assessment examination techniques 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.
CHAPTER 11 Caring for Children in Diverse Settings
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 636
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?
a. Plan for a short teaching session of about 30 minutes.
b. Tell the child that procedures are never a form of punishment.
c. Keep equipment out of the childs view.
d. Use correct scientific and medical terminology in explanations.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 639
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. The most appropriate nursing action is to:
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 639-640
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?
a. Avoid asking the child to make choices.
b. Demonstrate the procedure on a doll.
c. Plan for teaching session to last about 20 minutes.
d. Show necessary equipment without allowing child to handle it.
ANS: B
Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the childs
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 639
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. The most appropriate nursing action
is to:
a. grant her request.
b. explain why this is not possible.
c. identify an appropriate substitute for her mother.
d. offer to provide support to her during the procedure.
ANS: A
The parents preferences for assisting, observing, or waiting outside the room should be
assessed, along with the childs preference for parental presence. The childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 638
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. The nurses
action should be to:
a. ask the child to be quieter.
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b. have the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 641
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, an early sign of this disorder is:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 645-646
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. Pressurereduction 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 nonalkaline soap or soap-free
cleaning agents for routine bathing.
PTS: 1 DIF: Cognitive Level: Apply REF: 648
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. An appropriate intervention to encourage food and fluid intake in a hospitalized child is
to:
a. force child to eat and drink to combat caloric losses.
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b. discourage participation in noneating 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 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 childs hunger and further inhibit food intake.
PTS: 1 DIF: Cognitive Level: Apply REF: 649
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 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 650
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
nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 650
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). The nurse should explain that antipyretics:
a. may cause malignant hyperthermia.
b. may cause febrile seizures.
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c. are of no value in treating hyperthermia.
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 650-651
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. The nurses
action is to:
a. add isopropyl alcohol to the water.
b. direct a fan on the child in the bath.
c. stop the bath if the child begins to chill.
d. continue the bath for 5 minutes.
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 bodys 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 651
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. To identify the correct child, the nurses action is to:
a. ask the group, Who is Sam Hart?
b. call out to the group, Sam Hart?
c. ask each child, Whats your name?
d. check the patients identification name band.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 665
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection
Control
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15. The nurse wore gloves during a dressing change. When the gloves are removed, the
nurse should:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 654
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 patients 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 patients room.
b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside
of patients room.
c. Cap needle immediately after giving injection and dispose of in proper container.
d. Cap needle, break from syringe, and dispose of in 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 patients room. The uncapped needle should not be transported to an area distant
from use. Needles are disposed of uncapped and unbroken.
PTS: 1 DIF: Cognitive Level: Apply REF: 654
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. The nurses
best response is:
a. The doses are close enough; it doesnt 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 childrens dosage is based on a specific dose per
kilogram of body weight. The mother should be given correct information. For a
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therapeutic effect, the dosage should be based on weight, not age. Acetaminophen can be
used to relieve discomfort in children at this age group.
PTS: 1 DIF: Cognitive Level: Apply REF: 665
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. The
nurses action is to:
a. remove the restraints once a day to allow movement.
b. keep the restraints on constantly.
c. keep the restraints secure so infant remains supine.
d. remove restraints whenever possible.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 656
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. The nurse should recognize that this behavior is:
a. unsafe.
b. helpful to relax the child.
c. against hospital policy.
d. unnecessary because of childs age.
ANS: B
The mothers preference for assisting, observing, or waiting outside the room should be
assessed along with the childs preference for parental presence. The childs 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 641
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, the nurses best action is to:
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 puncture site 15 minutes before procedure.
ANS: A
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Because of the urgency of the childs 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 641
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?
a. Apply a urine-collection bag to perineal area.
b. Tape a small medicine cup to inside of diaper.
c. Aspirate urine from cotton balls inside diaper with a syringe.
d. Aspirate urine from superabsorbent disposable diaper with a syringe.
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 childs skin.
It is not feasible to tape a small medicine cup to inside of diaper; the urine will spill from
the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
PTS: 1 DIF: Cognitive Level: Apply REF: 659
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?
a. Clean technique, not standard precautions, is needed.
b. Insert 2% lidocaine lubricant into the urethra.
c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly.
d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 660
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?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 662
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. Which is
recommended to facilitate this?
a. Apply cool, moist compresses.
b. Apply a tourniquet to ankle.
c. Elevate foot for 5 minutes.
d. Wrap 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 662
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 arm extended while applying a bandage to the site.
b. Keep 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 662
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. Which 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 child only as needed to perform venipuncture safely.
d. Show child equipment to be used before procedure.
ANS: C
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Restrain 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 664
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. An appropriate method for administering oral medications that are bitter to an infant
or small child would be to mix them with:
a. a bottle of formula or milk.
b. any food the child is going to eat.
c. a small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream.
d. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 666
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
infants tongue.
b. Administer the medication as rapidly as possible with the infant securely restrained.
c. Mix the medication with the infants 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
infants 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 childs nasal passages will
increase the risk of aspiration.
PTS: 1 DIF: Cognitive Level: Apply REF: 666
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?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 667
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 dartlike 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 dartlike 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 671
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?
a. No need to keep exit site dry
b. Easy to use for self-administered infusions
c. Heparinized only monthly and after each infusion
d. No limitations on regular physical activity, including swimming
ANS: B
The Hickman-Broviac catheter has several benefits, including that it is easy to use for
self-administered 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 675
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?
a. In the conjunctival sac that is formed when the lower lid is pulled down
b. Carefully under the eye lid while it is gently pulled upward
c. On the sclera while the child looks to the side
d. Anywhere as long as drops contact the eyes surface
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 679
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?
a. It is less painful for small children.
b. Rapid venous access is not possible.
c. Antibiotics must be started immediately.
d. Long-term central venous access is not possible.
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 682
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
34. When caring for a child with an intravenous infusion, the nurse should:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 683
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
35. Nursing considerations related to the administration of oxygen in an infant include to:
a. humidify oxygen if infant can tolerate it.
b. assess infant to determine how much oxygen should be given.
c. ensure uninterrupted delivery of the appropriate oxygen concentration.
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d. direct oxygen flow so that it blows directly into the infants face in a hood.
ANS: C
Oxygen is a prescribed medication. It is the nurses 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 infants face.
PTS: 1 DIF: Cognitive Level: Understand REF: 687-688
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
because wiring that is incompatible can 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 second- and 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 689
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. To perform percussion, the
nurse should instruct her to:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 689
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. Interventions should include:
a. encouraging child to cough to raise the secretions before suctioning.
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b. selecting a catheter with diameter three fourths as large as the diameter of the
tracheostomy tube.
c. ensuring each pass of the suction catheter should take no longer than 5 seconds.
d. allowing 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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 691
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
39. When administering a gavage feeding to a school-age child, the nurse should:
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 on 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 700
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 701
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
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41. In preparing to give enemas until clear to a young child, the nurse should select which
solution?
a. Tap water
b. Normal saline
c. Oil retention
d. Fleet solution
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 701
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
42. The nurse is doing a prehospitalization 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 surgeons responsibility.
c. too stressful for a young child.
d. an appropriate part of the childs 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 640
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 is 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,
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thus generally being over 20 pounds. The site has less subcutaneous tissue, which
facilitates intramuscular (rather than subcutaneous) deposition of the drug.
PTS: 1 DIF: Cognitive Level: Understand REF: 667
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.
Handwashing 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 654
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 childs 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 665
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
2. A physicians 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.
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1 g = 1000 mg
Formula:
Desired Volume = 125 mg/1000 mg 7.4 ml = 0.925 round to 0.93 ml.
Available
PTS: 1 DIF: Cognitive Level: Analyze REF: 665
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 681
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
ESSAY
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 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 childs 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
CHAPTER 12 Caring for the Special Needs Child
MULTIPLE CHOICE
1. A parent comments that her infant has had several ear infections in the past few
months. The nurse understands that infants are more susceptible to otitis media because:
a
.
Infants are in a supine or prone position most of the time.
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b
.
Sucking on a nipple creates middle ear pressure.
c
.
They have increased susceptibility to upper respiratory
tract infections.
d
.
The eustachian tube is short, straight, and wide.
ANS: D
An infants eustachian tubes are shorter, wider, and straighter, allowing microorganisms
easy access to the middle ear.
DIF: Cognitive Level: Knowledge REF: 511 OBJ: 2
TOP: Otitis Media KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse determines a mother understands instructions about administering an oral
antibiotic for otitis media when the mother verbalizes that she will:
a
.
Continue using the medication until symptoms are
relieved.
b
.
Share the medicine with siblings if their symptoms are
the same.
c
.
Give the medication with a glass of milk.
d
.
Administer prescribed doses until all the medication is
used.
ANS: D
Antibiotic therapy for otitis media is continued until the prescribed amount has been
completed, even if symptoms are alleviated.
DIF: Cognitive Level: Application REF: 522 OBJ: 2
TOP: Otitis Media KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. The situation in which the nurse would be suspicious about a hearing impairment is:
a
.
A 3-month-old infant with a positive Moro reflex
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b
.
A 15-month-old toddler who is babbling
c
.
An 18-month-old toddler who is speaking one-syllable
words
d
.
A 24-month-old toddler who communicates by pointing
ANS: D
The child who is not making verbal attempts by 18 months should undergo a complete
physical examination.
DIF: Cognitive Level: Analysis REF: 523 OBJ: 3
TOP: Hearing Impairment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
4. The best way for the nurse to communicate with a 10-year-old child who has a hearing
impairment would be to:
a
.
Use gestures and signs as much as possible.
b
.
Let the childs parents communicate for her.
c
.
Face the child and speak clearly in short sentences.
d
.
Recognize that the childs ability to communicate will be
on a 6-year-old level.
ANS: C
The nurse who faces the child and speaks clearly will help the hearing-impaired child in
the hospital to develop a healthy personality.
DIF: Cognitive Level: Application REF: 523 OBJ: 3
TOP: Hearing Impairment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse planning postoperative teaching for a child who has had a tympanostomy
with insertion of tubes would include:
a
.
Keep the infant flat after feeding.
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b
.
Give over-the-counter anticongestants.
c
.
Avoid getting water in the ears.
d
.
Clean the ear canal with cotton-tipped applicators.
ANS: C
Following a tympanostomy, care should be taken to avoid getting water in the ears.
DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2
TOP: Postoperative Care of Tympanostomy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. The school nurse would suspect amblyopia when the child:
a
.
Has a reddened sclera in one eye
b
.
Covers one eye to read the board
c
.
Complains of a headache
d
.
Has copious tears while watching TV
ANS: B
Indicators of amblyopia include covering one eye to see, tilting the head to see, missing
objects in attempts to pick them up. Although headaches may be associated with
amblyopia, it is too vague to point suspicion to any disorder.
DIF: Cognitive Level: Analysis REF: 526 OBJ: 4
TOP: Amblyopia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
7. The nurse explains that a common treatment for amblyopia is:
a
.
Patching the good eye to force the brain to use the
affected eye
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b
.
Patching the affected eye to allow the refractory muscles
to rest
c
.
Using glasses that will slightly blur the image for the
good eye
d
.
Using corticosteroids to treat inflammation of the optic
nerve
ANS: A
Early detection and treatment are essential for the child with amblyopia. Treatment
includes patching the good eye and using glasses to correct refractive errors.
DIF: Cognitive Level: Knowledge REF: 526 OBJ: 4
TOP: Amblyopia KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
8. The school nurse recognizes the cardinal sign of a hyphema when she assesses:
a
.
Opacity of the lens
b
.
A yellow-white reflex on the pupil
c
.
A dark-red spot in front of the iris
d
.
Inflamed mucous membranes of the eyelids
ANS: C
A dark red spot in front of the iris is blood that has drained into the anterior chamber as
the result of an injury.
DIF: Cognitive Level: Knowledge REF: 527 OBJ: N/A
TOP: Retinoblastoma KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
9. The nurse is planning to teach parents about prevention of Reyes syndrome. What
information would the nurse include in this teaching?
a
.
Use aspirin instead of acetaminophen for children with
viral illness.
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b
.
Advise parents to have their children immunized against
Reyes syndrome.
c
.
Avoid giving salicylate-containing medications to a child
who has viral symptoms.
d
.
Get the child tested for Reyes syndrome if the child
exhibits fever, vomiting, and lethargy.
ANS: C
Prevention of Reyes syndrome includes educating parents not to give aspirin-containing
medication to children with viral symptoms.
DIF: Cognitive Level: Application REF: 529 OBJ: 11
TOP: Reyes Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
10. The nurse caring for a 5-month-old with viral influenza suspects the development of
Reyes syndrome when the child:
a
.
Has respirations drop from 18 to 14 breaths/min
b
.
Goes to sleep after feeding
c
.
Suddenly vomits
d
.
Develops a macular rash
ANS: C
A child with a viral infection is at risk for Reyes syndrome, the onset of which is
effortless vomiting, lethargy, and a change in LOC. A 5-month-old child that sleeps after
eating is normal.
DIF: Cognitive Level: Application REF: 529 OBJ: 11
TOP: Reyes Syndrome KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
11. The nurse explains that febrile seizures:
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a
.
Occur when the body temperature exceeds 103F
b
.
Can be prevented by anticonvulsant medication
c
.
Usually lead to the development of epilepsy
d
.
Occur when the temperature rises quickly
ANS: D
Febrile seizures occur in response to a rapid rise in temperature, often above 102F
(38.8C).
DIF: Cognitive Level: Comprehension REF: 533 OBJ: 9
TOP: Febrile Seizures KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. A parent reports that her child experiences episodes where he appears to be staring
into space. This behavior is characteristic of which type of seizure?
a
.
Absence
b
.
Akinetic
c
.
Myoclonic
d
.
Complex partial
ANS: A
Absence seizures are characterized by transient loss of consciousness where the child
appears to stare blankly, and which may last only a few seconds.
DIF: Cognitive Level: Analysis REF: 534, Table 23-2
OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. An adolescent has just had a generalized seizure lasting 1 minute. Following the
seizure, the nurse should:
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a
.
Help the patient to sit upright
b
.
Turn on the side
c
.
Offer ice chips
d
.
Assist to ambulate
ANS: B
During the tonic phase of a generalized seizure, the head, legs, and back stiffen.
DIF: Cognitive Level: Analysis REF: 534, Table 23-2
OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
14. When a child is experiencing a generalized tonic-clonic seizure, an appropriate
nursing action would be to:
a
.
Guide the child to the floor if the child is standing, and
then go for help.
b
.
Move objects out of the childs immediate area.
c
.
Stick a padded tongue blade between the childs teeth.
d
.
Manually restrain the child.
ANS: B
During a generalized tonic-clonic seizure, the immediate area is cleared to protect the
child from injury.
DIF: Cognitive Level: Application REF: 534, Table 23-2
OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
15. A child had a generalized tonic-clonic seizure that lasted 90 seconds. After a
generalized tonic-clonic seizure, the nurse would expect that the child might be:
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a
.
Restless
b
.
Sleepy
c
.
Nauseated
d
.
Anxious
ANS: B
Following a generalized tonic-clonic seizure, the child may have some confusion and
may sleep for a time (postictal lethargy) and then return to full consciousness.
DIF: Cognitive Level: Analysis REF: 535 OBJ: 9
TOP: Epilepsy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. The nurse would include in a teaching plan pertinent to the long-term administration
of Dilantin that:
a
.
The medication should be given with food to reduce
gastrointestinal distress.
b
.
Behavioral changes are a possible side effect.
c
.
Gums should be massaged regularly to prevent
hyperplasia.
d
.
Blood pressure should be closely monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular massaging.
DIF: Cognitive Level: Application REF: 536 OBJ: 9
TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and
the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes
that he has which type of cerebral palsy?
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a
.
Athetoid
b
.
Ataxic
c
.
Spastic
d
.
Mixed
ANS: C
Spasticity is characterized by tension in certain muscle groups, which makes voluntary
movements of muscles jerky and uncoordinated.
DIF: Cognitive Level: Analysis REF: 536 OBJ: 10
TOP: Cerebral Palsy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. The assessment finding that should be reported immediately if observed in a child
with meningitis is:
a
.
Irregular respirations
b
.
Tachycardia
c
.
Slight drop in blood pressure
d
.
Elevated temperature
ANS: A
Irregular respirations in conjunction with slowing heart rate and increasing blood
pressure are reported immediately because they could indicate increased intracranial
pressure.
DIF: Cognitive Level: Analysis REF: 530 OBJ: 15
TOP: Meningitis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
19. The nurse observes a childs position is supine with his arms and legs rigidly extended
and the hands pronated. The nurse recognizes this posture as:
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a
.
Correct anatomical position
b
.
Decorticate
c
.
Decerebrate
d
.
Opisthotonos
ANS: C
In decerebrate posturing, arms are extended along the side of the body and hands are
pronated. This posture indicates brainstem function only.
DIF: Cognitive Level: Analysis REF: 542 OBJ: 14
TOP: Posturing KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. The nurse giving instructions for acute conjunctivitis would teach parents to:
a
.
Apply cool compresses to the affected eye several times
a day.
b
.
Instill topical steroid eye drops for 1 week.
c
.
Clear away drainage from the inner to the outer aspect of
the eye.
d
.
Keep the eye patched until the inflammation resolves.
ANS: C
Eye secretions are always cleared from the inner canthus downward and away from the
opposite eye (inner to outer direction).
DIF: Cognitive Level: Application REF: 526 OBJ: N/A
TOP: Conjunctivitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
21. A child is brought to the emergency department after he fell and hit his head on the
ground. The nursing assessment that suggests the child has a concussion is:
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a
.
Sleepy but easily arousable
b
.
Complaining of a stiff neck
c
.
Cannot remember what happened to him
d
.
Pupils react sluggishly to light
ANS: C
A concussion is a temporary disturbance of the brain that is immediately followed by a
period of unconsciousness. It is accompanied often by a loss of memory of the events that
occurred immediately before, during, or after the injury.
DIF: Cognitive Level: Analysis REF: 543 OBJ: N/A
TOP: Head Injury KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22. A child is admitted to the hospital because she had a seizure. Her parents report that
for the past few weeks she has had headaches that are worse in the morning with
vomiting. The nurse would suspect:
a
.
Meningitis
b
.
Reyes syndrome
c
.
Brain tumor
d
.
Encephalitis
ANS: C
The signs and symptoms of a brain tumor are related to its size and location. Most tumors
create increased ICP with the hallmark symptoms of headache, vomiting, drowsiness, and
seizures.
DIF: Cognitive Level: Analysis REF: 532 OBJ: 15
TOP: Brain Tumor KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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MULTIPLE RESPONSE
1. The pediatric nurse is alerted to the probability of an ear infection in a 6-month-old
child when the baby:
Select all that apply.
a
.
Is hypersensitive to noise
b
.
Is irritable
c
.
Has a reddened ear canal
d
.
Rolls head from side to side
e
.
Spikes a temperature of 103F
ANS: B, D, E
Infants signal ear infections by being irritable, spiking a temperature, rolling their heads
from side to side, and pulling at or rubbing their ears.
DIF: Cognitive Level: Application REF: 521 OBJ: 2
TOP: Indications of Ear Infection KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
2. The nurse cautions parents that hearing impairment can affect the childs:
Select all that apply.
a
.
Speech clarity
b
.
Language development
c
.
Emotional stability
d
.
Personality development
e
.
Academic achievement
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ANS: A, B, C, D, E
All the options are areas in which a hearing impairment could interfere with normal
development.
DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2
TOP: Hearing Impairment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
3. The nurse, preparing air travel instructions to prevent barotraumas in infants, would
include:
Select all that apply.
a
.
Using ear plugs during takeoff
b
.
Holding baby upright during flight
c
.
Omitting the meal just before takeoff
d
.
Letting the baby nurse during descent
e
.
Applying ear drops before takeoff
ANS: D
Encouraging an infant to swallow reduces the pressure in the ears during descent.
DIF: Cognitive Level: Comprehension REF: 524 OBJ: 2
TOP: Barotrauma KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
4. The nurse caring for a child with infectious meningitis, would include in the care:
Select all that apply.
a
.
Isolation precautions
b
.
Provision of dimly lit room
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c
.
Observation for increasing intracranial pressure
d
.
Preparation for spinal tap
e
.
Seizure precautions
ANS: A, B, C, D, E
All elements of nursing care listed in the options would be part of comprehensive care of
a child with meningitis.
CHAPTER 13 Key Pediatric Nursing Interventions
MULTIPLE CHOICE
1. When the nurse notes that an infant can lift her head before she can sit, the nurse is
assessing:
a
.
Specific to general development
b
.
Proximodistal development
c
.
Cephalocaudal development
d
.
General to specific development
ANS: C
Cephalocaudal development proceeds from head to toe.
DIF: Cognitive Level: Comprehension REF: Text Reference: 348
OBJ: Objective: 2
TOP: Topic: Directional Patterns of Development
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
2. A unique organization of characteristics that determines an individuals pattern of
behavior is known as:
a
.
Environment
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b
.
Heredity
c
.
Personality
d
.
Experience
ANS: C
One definition of personality states that it is a unique organization of characteristics that
determines the individuals typical or recurrent pattern of behavior.
DIF: Cognitive Level: Knowledge REF: Text Reference: 355
OBJ: Objective: 5 TOP: Topic: Personality Development
KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Maintenance and Promotion
3. An infants birthweight is 7 pounds, 8 ounces. The nurse can project the weight at 6
months to be:
a
.
12 pounds
b
.
15 pounds
c
.
18 pounds
d
.
22 pounds
ANS: B
An infant usually doubles his or her birth weight by 5 to 6 months.
DIF: Cognitive Level: Application REF: Text Reference: 349
OBJ: Objective: 4 TOP: Topic: Growth
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse assessing patterns of growth in a child would investigate further if:
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a
.
Previous weight was in the 75th percentile, and present
weight is in the 25th percentile.
b
.
Height is in the 90th percentile, and weight is in the 75th
percentile.
c
.
Last weight was in the 5th percentile, and present weight
is in the 10th percentile.
d
.
Weight is in the 50th percentile, and siblings weight at
the same age was in the 75th percentile.
ANS: A
The child showing a difference of two or more percentile levels from an established
growth pattern should undergo further evaluation.
DIF: Cognitive Level: Analysis REF: Text Reference: 351
OBJ: Objective: 3 TOP: Topic: Growth
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. A mother reports that she and her husband have had one child together, but both have
children from previous marriages living in their home. The nurse will base the care
planning on the fact this family type is a:
a
.
Nuclear family
b
.
Blended family
c
.
Alternate family
d
.
Extended family
ANS: B
A blended family involves the remarriage of persons with children.
DIF: Cognitive Level: Comprehension REF: Text Reference: 354, Table 15-1
OBJ: Objective: 9 TOP: Topic: The Family
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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6. The mother of a 7-month-old reports that the first lower central incisor has erupted.
She asks the nurse, How many teeth will he have by his first birthday? The nurse would
explain that by 1 year of age, the infant usually has:
a
.
Two teeth
b
.
Four teeth
c
.
Six teeth
d
.
Eight teeth
ANS: C
The 1-year-old infant usually has about six teeth, four above and two below.
DIF: Cognitive Level: Comprehension REF: Text Reference: 375
OBJ: Objective: 8 TOP: Topic: Dentition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
7. At a well-baby visit, parents of a 6-month-old ask when to take the infant for the first
dental visit. The nurses best response would be:
a
.
If the teeth are brushed regularly, the child should see a
dentist by 3 years of age.
b
.
The first dental visit should be arranged after the first
tooth erupts.
c
.
The child should have a dental examination when all
deciduous teeth have erupted.
d
.
A dental visit by 1 year of age is recommended by the
American Academy of Pediatric Dentistry.
ANS: D
The Academy of Pediatric Dentistry recommends that the first dental visit occur by 1 year
of age.
DIF: Cognitive Level: Application REF: Text Reference: 375
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OBJ: Objective: 8 TOP: Topic: Dentition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Maintenance and Promotion: Prevention and Early Detection of
Disease
8. The nurse planning anticipatory guidance for the caregiver of a preschool-age child
would explain that permanent teeth begin erupting about the age of:
a
.
4 years
b
.
6 years
c
.
8 years
d
.
10 years
ANS: B
Permanent teeth do not erupt through the gums until the sixth year.
DIF: Cognitive Level: Comprehension REF: Text Reference: 375
OBJ: Objective: 8 TOP: Topic: Dentition
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
9. A mother asks the nurse how much food should be offered to her 2-year-old. The nurse
responds that a good rule of thumb for serving size would be:
a
.
2 tablespoons
b
.
3 tablespoons
c
.
4 tablespoons
d
.
5 tablespoons
ANS: A
The rule of thumb for serving sizes is to offer 1 tablespoon per year of age.
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DIF: Cognitive Level: Application REF: Text Reference: 374
OBJ: Objective: 7 TOP: Topic: Rule of Thumb for Serving Sizes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
10. An assessment of a childs nutritional status reveals the child is alert, with shiny hair,
firm gums, firm mucous membranes, and regular elimination. This childs nutritional
status would be described as:
a
.
Overnourished
b
.
Undernourished
c
.
Well nourished
d
.
Borderline
ANS: C
Well-nourished children show steady gains in height and weight and have shiny hair, firm
gums and mucous membranes, and regular elimination.
DIF: Cognitive Level: Analysis REF: Text Reference: 374
OBJ: Objective: 7 TOP: Topic: Nutrition
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. The nurse encourages a Puerto Rican family to bring food to a child because he is not
eating the food served on his tray at the hospital. The nurse would expect the child to eat:
a
.
Dried beans mixed with rice
b
.
Crisp vegetables
c
.
Spaghetti and meatballs
d
.
Wild berries, roots, and seeds
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ANS: A
A common food choice of Americans of Puerto Rican descent is dried beans mixed with
rice.
DIF: Cognitive Level: Analysis REF: Text Reference: 364, Table 15-5
OBJ: Objective: 9 TOP: Topic: Feeding the Ill Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. The
nurse recognizes that being able to feed himself is important to the toddler in developing:
a
.
Good nutrition
b
.
A sense of independence
c
.
Adequate height and weight
d
.
Healthy teeth
ANS: B
By the end of the second year, toddlers can feed themselves. This helps them to develop a
sense of independence.
DIF: Cognitive Level: Comprehension REF: Text Reference: 373, Table 15-3
OBJ: Objective: 7 TOP: Topic: Feeding the Healthy Child
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
13. To meet Eriksons developmental task of industry, the nurse caring for a 7-year-old
would choose an activity such as:
a
.
Working a jigsaw puzzle
b
.
Looking at a comic book
c
.
Playing a competitive board game
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d
.
Coloring a picture in a coloring book
ANS: A
In the developmental period of late childhood, children are striving to develop a sense of
industry. The completion of a jigsaw puzzle is industrious play.
DIF: Cognitive Level: Analysis REF: Text Reference: 363,Table 15-3
OBJ: Objective: 6 TOP: Topic: Personality Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
14. The nurse recognizes Piagets concrete operational thinking when:
a
.
A 2-year-old says, Its night time when his room is
darkened.
b
.
A 4-year-old refers to the hospital as my house.
c
.
A 5-year-old coloring a picture of a puppy says, This is
my puppy.
d
.
A 7-year-old says, I am sick because I have germs in my
chest.
ANS: D
The 7-year-olds remark reflecting the cause and effect of germs and illness is an example
of operational thinking. All other options are examples of preoperational thought, which
is egocentric and symbolic.
DIF: Cognitive Level: Analysis REF: Text Reference: 362, Table 15-4
OBJ: Objective: 6 TOP: Topic: Cognitive Development
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
15. The nurse has discussed with the mother about introducing solid foods to the 6month-old infant. The nurse determines that the mother understands the information
when she states the first food she will give to the infant is:
a
.
Rice cereal
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b
.
Yellow vegetables
c
.
Egg yolks
d
.
Fruits
ANS: A
Solid foods are usually introduced at about 6 months of age starting with rice cereal,
which is the least allergenic.
DIF: Cognitive Level: Comprehension REF: Text Reference: 373
OBJ: Objective: 7 TOP: Topic: Feeding the Healthy Child
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
16. When the 8-year-old child comes to the school nurse with his central incisor in his
hand and reports he knocked his tooth out on the water fountain, the nurse should:
a
.
Give him an ice cube to suck on.
b
.
Have him wash his mouth out with peroxide and water.
c
.
Wrap the tooth in a clean tissue.
d
.
Wash off the tooth and place it in a container of milk.
ANS: D
The tooth should be washed off and put in a container of milk to preserve it for possible
reimplantation.
DIF: Cognitive Level: Application REF: Text Reference: 373
OBJ: Objective: 8 TOP: Topic: Loss of Tooth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
17. The mother of a 7-month-old states, The baby is eating food now. Should I give him
regular milk, too? The nurse would respond:
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a
.
You should give the baby low-fat milk.
b
.
Try the milk. See if he has any digestive problems.
c
.
Continue breast milk or iron-fortified formula until 1
year of age.
d
.
At this age, infants can tolerate a lactose-free or soybased milk.
ANS: C
Whole milk should not be introduced before 1 year of age. Low-fat milk should not be
introduced before 2 years of age.
DIF: Cognitive Level: Application REF: Text Reference: 370
OBJ: Objective: 7 TOP: Topic: Nutrition and Health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. When a small group of preschool-age children were playing house, each child was
pretending to be a particular family member. The nurse recognizes this as which type of
play?
a
.
Parallel
b
.
Cooperative
c
.
Symbolic
d
.
Fantasy
ANS: B
In cooperative play, children play with each other, each taking a specific role.
DIF: Cognitive Level: Analysis REF: Text Reference: 376, Table 15-12
OBJ: Objective: 10 TOP: Topic: Play
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
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19. When the nurse asks the 10-year-old American Indian if he is ready to go to therapy,
he does not answer immediately. The nurse assesses this as:
a
.
Indecision
b
.
Considering the answer in silence
c
.
Shyness with strangers
d
.
Fear of medical personnel
ANS: B
Native Americans value silence. They need to sit and consider matters before replying to
questions.
DIF: Cognitive Level: Analysis REF: Text Reference: 360, Table 15-2
OBJ: Objective: 9
TOP: Topic: Ethnic Considerations-American Indian
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
20. A mother tells the nurse, My 11-month-old son is not as active as my other children
were at this age. He is the youngest of four and the older children love to dote on him.
Which factor is influencing this childs language development?
a
.
Heredity
b
.
Sex
c
.
Mothers health during pregnancy
d
.
Ordinal position
ANS: D
Motor development of the youngest child may be prolonged if the child is babied by
others in the family.
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DIF: Cognitive Level: Analysis REF: Text Reference: 353
OBJ: Objective: 4 TOP: Topic: Factors Influencing Development
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
21. The nurse explains that when a mother tells her 4-year-old child that balls should be
played with outside and not inside the house, the child is likely to obey the rule because
she:
a
.
Does not want to be punished
b
.
Wants to please her mother
c
.
Respects authority figures
d
.
Believes that following the rules is right
ANS: A
According to Kohlberg, children in the preconventional stage (4 to 7 years) are obedient
to their parents for fear of punishment.
DIF: Cognitive Level: Analysis REF: Text Reference: 361
OBJ: Objective: 6 TOP: Topic: Moral Development
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Maintenance and Promotion: Growth and Development
22. When demonstrating a bath procedure to parents of Vietnamese origin, the nurse
should avoid:
a
.
Talking directly to the mother
b
.
Exposing the childs genitals
c
.
Touching the childs head
d
.
Using cool water
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ANS: C
The Vietnamese are very sensitive about anyone touching a childs head because that is
where consciousness lies.
DIF: Cognitive Level: Application REF: Text Reference: 354, Table 15-2
OBJ: Objective: 3
TOP: Topic: Ethnic Considerations-Vietnamese
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
MULTIPLE RESPONSE
1. The pediatric nurse reminds a group of parents that children differ from adults in that
children have:
Select all that apply.
a
.
A higher metabolic rate
b
.
A greater surface area in relation to their weight
c
.
Less mature organ systems
d
.
Ineffective immune systems
e
.
A continuously changing growth and development
pattern
ANS: A, B, C, E
Children are in a continuous growth and development pattern. Children have a greater
surface area and a higher metabolic rate. All of their organ systems are not mature.
DIF: Cognitive Level: Comprehension REF: Text Reference: 348
OBJ: Objective: 2 TOP: Topic: Adult Versus Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. To introduce a toddler to new foods, the nurse suggests:
Select all that apply.
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a
.
Serve one food at a time.
b
.
Avoid showing personal likes or dislikes.
c
.
Offer foods in small amounts, less than a teaspoon.
d
.
Entice the toddler to eat with sweets.
e
.
Serve food warm.
ANS: A, B, C, E
Foods should be introduced in small, warm servings, one food at a time. Sweets and milk
should not be offered until after solid food.
DIF: Cognitive Level: Application REF: Text Reference: 374
OBJ: Objective: 3 TOP: Topic: Solid Food
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
1. The nurse includes in the care plan for a Hispanic family to encourage visits from the
______ ____________ or _______________ for a healing ceremony.
ANS: folk healer or curandero
DIF: Cognitive Level: Application REF: Text Reference: 356, Table 15-2
OBJ: Objective: 9 TOP: Topic: Folk Healer or Curandero
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
NOT: Rationale: Hispanics have faith in the effect of the curandero and are soothed by
the ceremonies.
2. The nurse assesses an unmet need in a hospitalized child who clings to his mother as
she is about to leave. The basic needs, as described by Maslow, that are unmet in this case
are: __________ and ____________________.
ANS: love, belongingness
DIF: Cognitive Level: Application REF: Text Reference: 361, Table 15-2
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OBJ: Objective: 6 TOP: Topic: Maslows Hierarchy
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Adaptation: Coping and Adaptation
NOT: Rationale: The child feels loss of love and the belonging of the family unit.
3. The nurse cautions that children who are put to sleep with a bottle are at risk for a
dental problem called ______ _____________.
ANS: milk caries
CHAPTER 14 Nursing Care of the Child With an Alteration in Comfort–Pain Assessment
and Management
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 doesnt 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
self-report 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 145 | 150
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
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 145
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 151
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Physiologic Integrity
4. Physiologic measurements in childrens 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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 145
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 childs pain
severity and taught to the child before the onset of the painful experience. Some of the
techniques may facilitate the childs experience with mild pain, but the child will still
know the discomfort was present.
PTS: 1 DIF: Cognitive Level: Understand REF: 159
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 162 | 164
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. A lumbar puncture is needed on a school-age child. The most appropriate action to
provide analgesia during this procedure is to apply _____ before the procedure.
a.
TAC (tetracaine-adrenaline-cocaine) 15 minutes
b.
transdermal fentanyl (Duragesic) patch immediately
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c.
EMLA (eutectic mixture of local anesthetics) 1 hour
d.
EMLA (eutectic mixture of local anesthetics) 30 minutes
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 167-168
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. The most appropriate management of this child is for the nurse to:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 169 | 172
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
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 147 | 150
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 153
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.
Diarrhea
b.
Respiratory depression
c.
Hypertension
d.
Pruritus
e.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 153 | 172
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.)
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a.
Bran cereal
b.
Decrease fluid intake
c.
Prune juice
d.
Cheese
e.
Vegetables
ANS: A, D, 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 165-166
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 167
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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 164
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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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
2
Face
No particular
expression or
smile
Occasional
grimace or
frown,
withdrawn,
disinterested
Frequent to
constant
frown,
clenched
jaw,
quivering
chin
Legs
Normal
position or
relaxed
Uneasy,
restless, tense
Kicking or
legs drawn
up
Activit
y
Lying quietly,
normal
position,
moves easily
Squirming,
shifting back
and forth,
tense
Arched,
rigid, or
jerking
Cry
No cry
(awake or
asleep)
Moans or
whimpers,
occasional
complaint
Crying
steadily,
screams or
sobs,
frequent
complaints
Consol
ability
Content,
relaxed
Reassured by
occasional
touching,
hugging, or
talking to;
distractible
Difficult to
console or
comfort
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 148
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
ESSAY
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 patients 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.
CHAPTER 15 Nursing Care of the Child With an Infection
MULTIPLE CHOICE
1. The nurse takes into consideration that the child most susceptible to an opportunistic
infection is the one taking:
a
.
Anticonvulsants
b
.
A beta-adrenergic agent
c
.
An antibiotic
d
.
Corticosteroids
ANS: D
Steroids are immunosuppressive drugs that make the child very susceptible to
opportunistic infections.
DIF: Cognitive Level: Analysis REF: Text Reference: 717
OBJ: Objective: N/A TOP: Topic: Host Resistance
KEY: Nursing Process Step: Assessment
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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. When the 8-year-old asks the nurse how she got the antibodies that kept her from
getting whooping cough, the nurse explains that those shots:
a
.
Were borrowed antibodies from another person who had
whooping cough
b
.
Gave her a tiny case of whooping cough and then she
made her own antibodies
c
.
Strengthened antibodies she was born with
d
.
Are only temporary borrowed antibodies and she needs
to have another shot every 5 years
ANS: B
Vaccines contain live weakened or dead organisms not strong enough to cause disease but
they stimulate the body to develop an immune reaction and antibodies. This is active
acquired immunity.
DIF: Cognitive Level: Knowledge REF: Text Reference: 717
OBJ: Objective: 3 TOP: Topic: Types of Immunity
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse would document a rash that has erythematous circular raised lesions as:
a
.
Macular
b
.
Papular
c
.
Vesicular
d
.
Pustular
ANS: B
A papule is a circular, reddened elevated area on the skin.
DIF: Cognitive Level: Knowledge REF: Text Reference: 718
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OBJ: Objective: 6 TOP: Topic: Rashes
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. The nurse would delay the administration of DTaP when the mother says that her
infant:
a
.
Has diarrhea
b
.
Had a temperature of 105 F from the previous
inoculation
c
.
Is teething
d
.
Is traveling with her to Europe in a week
ANS: B
A contraindication to giving the DTaP vaccine is a 105 F temperature following the
previous vaccination.
DIF: Cognitive Level: Analysis REF: Text Reference: 721
OBJ: Objective: 4 TOP: Topic: Immunizations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. The type of precaution that is necessary when caring for a toddler with varicella is:
a
.
Contact
b
.
Protective
c
.
Airborne infection
d
.
Large droplet infection
ANS: C
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Airborne-infection precautions are used for patients with conditions such as tuberculosis,
varicella, and rubeola. Small airborne particles caught on floating dust in the room can be
inhaled from anywhere in the room.
DIF: Cognitive Level: Application REF: Text Reference: 718
OBJ: Objective: 2 TOP: Topic: Medical Asepsis and Standard Precautions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
6. A parent is concerned because her son was exposed to varicella at preschool. The nurse
would tell this parent that the incubation period for varicella is:
a
.
2 to 10 days
b
.
4 to 14 days
c
.
3 to 32 days
d
.
14 to 21 days
ANS: D
The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days.
DIF: Cognitive Level: Knowledge REF: Text Reference: 713, Table 31-1
OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
7. The nurse can be assured that parents understand how long a child who has varicella is
contagious when they state:
a
.
My child should stay home from school for 6 days after
the pox appear.
b
.
My child can return to school when the rash fades.
c
.
My child must stay away from other children until all of
the lesions have healed.
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d
.
My child is contagious as long as he has a fever.
ANS: A
The child with varicella is contagious for 6 days after the appearance of the rash.
DIF: Cognitive Level: Application REF: Text Reference: 713, Table 31-1
OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
8. The statement made by a sexually active adolescent girl indicating an understanding of
the prevention of sexually transmitted diseases is:
a
.
I always douche after intercourse.
b
.
I think you can get a vaccination for STDs now.
c
.
I insist that my partner wear a condom.
d
.
I am protected because I take the pill.
ANS: C
The use of condoms to prevent STDs is not considered 100% effective but is
recommended for sexual intercourse.
DIF: Cognitive Level: Application REF: Text Reference: 725
OBJ: Objective: 8 TOP: Topic: Sexually Transmitted Diseases
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
9. The priority nursing diagnosis for a hospitalized infant who is HIV-positive would be:
a
.
Risk for injury
b
.
Altered nutrition
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c
.
Impaired skin integrity
d
.
Risk for infection
ANS: D
The infant who is HIV-positive has impaired immunologic functioning and is at high risk
for infection.
DIF: Cognitive Level: Analysis REF: Text Reference: 725
OBJ: Objective: 7 TOP: Topic: Human Immunodeficiency Virus
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
10. A parent of a newborn asked the nurse, When will my baby get the hepatitis B
vaccine? The nurse bases a response on the knowledge that the first dose of Comvax
should be given to infants born to a hepatitis B-negative mother at:
a
.
2 months
b
.
4 months
c
.
6 months
d
.
1 year
ANS: B
The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free
hepatitis B vaccine, should be used for infants born to HBsAg-negative mothers
beginning at the 2-month well-child visit.
DIF: Cognitive Level: Knowledge REF: Text Reference: 722, Figure 31-6
OBJ: Objective: 4 TOP: Topic: Immunization Schedule
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
11. The nurse would base a response to a parent about how his child got hepatitis A on the
information that the child:
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a
.
Came in contact with infected blood
b
.
Came in contact with droplets in the air
c
.
Was bitten by a mosquito or a tick
d
.
Ate shrimp while they were in Mexico
ANS: D
Hepatitis A results from ingestion of contaminated water or shellfish.
DIF: Cognitive Level: Comprehension REF: Text Reference: 714, Table 31-1
OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
12. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the
nurse use when caring for the infant?
a
.
Large-droplet infection precautions
b
.
Airborne-infection precautions
c
.
Contact precautions
d
.
Protective precautions
ANS: C
Contact precautions are used when the condition transmits organisms via skin-to-skin
contact or indirect touch of a contaminated fomite.
DIF: Cognitive Level: Application REF: Text Reference: 718
OBJ: Objective: 2 TOP: Topic: Medical Asepsis and Standard Precautions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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13. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What
is the most appropriate response for the nurse to make when the child asks, Why do you
have to wear a gown and mask when you are in my room?
a
.
Nurses and doctors wear gowns and masks because you
have a condition that could be spread to others.
b
.
The gown and mask are to protect you because you could
get an infection very easily.
c
.
Im wearing this because there are a lot of bacteria in the
hospital.
d
.
I might look scary but you wont need this after you have
had medication for 24 hours.
ANS: B
Protective isolation is used for patients who are not communicable but have a lowered
resistance and are highly susceptible to infection.
DIF: Cognitive Level: Application REF: Text Reference: 718
OBJ: Objective: 2 TOP: Topic: Protective Isolation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
14. The nurse is planning to administer immunizations at a well-child visit when a parent
reports the 18-month-old child is allergic to eggs. The vaccine that would be
contraindicated is:
a
.
Influenza
b
.
Inactivated polio vaccine
c
.
Diphtheria, tetanus, acellular pertussis
d
.
Hepatitis B
ANS: A
The influenza vaccine should not be given to children who have an allergy to eggs.
DIF: Cognitive Level: Analysis REF: Text Reference: 720
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OBJ: Objective: 3 TOP: Topic: Nurses Role in Immunizations-Allergy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
15. The nurse would choose to administer the immunization injection of:
a
.
DTaP subcutaneously
b
.
Hib vaccine prepared in a separate syringe
c
.
Varicella intramuscularly
d
.
Varicella 1 week after the MMR vaccine
ANS: B
Hib vaccine must be given in a separate syringe from other vaccines administered at the
same time.
DIF: Cognitive Level: Analysis REF: Text Reference: 722, Figure 31-6
OBJ: Objective: 3 TOP: Topic: Nurses Role in Immunizations
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
16. A child was sent to the school nurse because of a rash. The nurse noted the rash was
present on the trunk, extremities, and face. The childs cheeks were bright red. The nurse
is aware this type of rash is consistent with:
a
.
Measles
b
.
Roseola
c
.
Varicella
d
.
Fifth disease
ANS: D
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When a child has fifth disease, the child has a generalized rash and the cheeks have a
slapped cheek appearance.
DIF: Cognitive Level: Application REF: Text Reference: 713, Table 31-1
OBJ: Objective: 6 TOP: Topic: Common Childhood Communicable Diseases
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
17. The nurse determined the parent understood the information when he stated:
a
.
Ill have my son wear dark clothing on his hike.
b
.
We should all get the Lyme disease vaccine before our
trip.
c
.
Ill get a prescription for amoxicillin to take with us.
d
.
We will wear long pants and long-sleeved shirts in the
woods.
ANS: D
People should keep skin covered by wearing protective clothing in wooded areas to
prevent tick bites.
DIF: Cognitive Level: Application REF: Text Reference: 715, Table 31-1
OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
18. An adolescent is taking tetracycline for a sexually transmitted disease. The nurse
would stress in the instruction about this medication to:
a
.
Finish all of the medication.
b
.
Get plenty of fresh air and sunlight.
c
.
The medication should be taken with food.
d
.
Take an antacid if the medication causes an upset
stomach.
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ANS: A
The nurse would teach the adolescent to take all of the prescribed medication to avoid
making the microorganism resistant to tetracyclines.
DIF: Cognitive Level: Application REF: Text Reference: 724, Table 31-3
OBJ: Objective: 8 TOP: Topic: Sexually Transmitted Diseases
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
19. The nurse explains to the parents that their child is in the prodromal stage of varicella.
This means that the child:
a
.
Is now immune to varicella
b
.
Has varicella, but has not yet broken out
c
.
Is infected with varicella, but is not contagious
d
.
Does not have varicella, but has been exposed to it
ANS: B
The prodromal stage is the initial stage of the communicable disease in which the child is
infected and contagious, but does not yet have outward signs of the disease.
DIF: Cognitive Level: Application REF: Text Reference: 716
OBJ: Objective: 1 TOP: Topic: Prodromal Period
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. In giving care, the nurse is aware that safe handling of body substances is essential.
Body substances that require safe handling are:
Select all that apply.
a
.
Emesis
b
.
Saliva
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c
.
Feces
d
.
Semen
e
.
Blood
ANS: A, B, C, D, E
All the options listed are considered body substances that are moist secretions capable of
containing microorganisms.
DIF: Cognitive Level: Comprehension REF: Text Reference: 716
OBJ: Objective: 1 TOP: Topic: Body Substances
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. The well-child clinic nurse will prepare to give a healthy 2-month-old inoculations for:
Select all that apply.
a
.
DTaP
b
.
Hib
c
.
IPV
d
.
MMR
e
.
PCV
ANS: A, B, C, E
All the options are the expected inoculations of a healthy 2-month-old with the exception
of MMR. Mumps, measles, rubella are not expected until the child is 1-year-old.
DIF: Cognitive Level: Application REF: Text Reference: 722, Figure 31-6
OBJ: Objective: 3 TOP: Topic: Inoculations for a 2-Month-Old
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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COMPLETION
1. The nurse explains ____________________ test determines the childs susceptibility to
tuberculosis.
ANS: Mantoux
DIF: Cognitive Level: Knowledge REF: Text Reference: 717
OBJ: Objective: 4 TOP: Topic: Mantoux
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
NOT: Rationale: The Mantoux is a screening test for the susceptibility to TB. An
intradermal injection is given and read 3 days later. An erythema and induration of more
than 5 mm is considered a positive reading.
2. The nurse uses a diagram showing how the wood tick acts as a
____________________ in the transmission of Lyme disease.
ANS: vector
DIF: Cognitive Level: Comprehension REF: Text Reference: 716
OBJ: Objective: 4 TOP: Topic: Vector
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
NOT: Rationale: A vector is an insect or animal that carries a communicable disease.
3. The school nurse recognizes the presence of macules, papules, vesicles, pustules, and
scabs on the child as the particular sign of the communicable disease of
____________________.
ANS: varicella or chickenpox
CHAPTER 16 Nursing Care of the Child With an Alteration in Intracranial Regulation/
Neurologic Disorder
MULTIPLE CHOICE
1. The nurse has documented that a childs level of consciousness is obtunded. Which
describes this level of consciousness?
a. Slow response to vigorous and repeated stimulation
b. Impaired decision making
c. Arousable with stimulation
d. Confusion regarding time and place
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 929
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 928
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 patients 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 929
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. The nurse should interpret this as:
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
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 942
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?
a. Papilledema
b. Delirium
c. Dolls head maneuver
d. Periodic and irregular breathing
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 ICP. Delirium is a state of mental
confusion and excitement marked by disorientation for time and place. The dolls head
maneuver is a test for brainstem or oculomotor nerve dysfunction.
PTS: 1 DIF: Cognitive Level: Understand REF: 930
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?
a. Oculovestibular response
b. Dolls head maneuver
c. Funduscopic examination for papilledema
d. Assessment of pyramidal tract lesions
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 an awake
child or one who has a ruptured tympanic membrane. Dolls head maneuver, funduscopic
examination for papilledema, and assessment of pyramidal tract lesions can be performed
on awake children.
PTS: 1 DIF: Cognitive Level: Analyze REF: 931
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,
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sedation is sometimes necessary. Someone is able to remain with the child during the
procedure.
PTS: 1 DIF: Cognitive Level: Apply REF: 933
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 crosssection of the brain at any axis?
a. Nuclear brain scan
b. Echoencephalography
c. CT scan
d. Magnetic resonance imaging (MRI)
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 933
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 935
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 936
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
11. An appropriate nursing intervention when caring for an unconscious child should be
to:
a. change the childs 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 childs
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 937
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 939-940
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?
a. Involves the basilar portion of the occipital bone
b. Bone is exposed through the skin
c. Traumatic separations of the cranial sutures
d. Bone is pushed inward, causing pressure on the brain
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 940
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 940-941
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. The nurse should recommend medical attention if a child with a slight head injury
experiences:
a. sleepiness.
b. vomiting, even once.
c. headache, even if slight.
d. confusion or 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 943-944
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. The next nursing action:
should be to
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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 942
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 930
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. The nurse should recognize that this suggests:
a. diabetic coma.
b. brainstem injury.
c. upper respiratory tract infection.
d. leaking of cerebrospinal fluid (CSF).
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 942
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 childs 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 childs 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
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CT scan is related to the injury and symptoms, not the childs age. The CT scan is
necessary to determine whether a brain injury has occurred.
PTS: 1 DIF: Cognitive Level: Apply REF: 933
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 childs 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 929
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 childs level of consciousness is variable. The parents tell the
nurse that they think their child is in pain because of periodic crying and restlessness. The
most appropriate nursing action is to:
a. discuss with parents the childs 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 childs neurologic status and the promotion of comfort and relief of anxiety.
Information on the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 944
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 944
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 childs mother
complains to the nurse, Being at the hospital seems unnecessary when he is perfectly fine.
The nurses best reply should be:
a. He still needs a little extra oxygen.
b. Im 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 945
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The most common clinical manifestation(s) of brain tumors in children is/are:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 947
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. 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.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 948
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
26. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 949
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 950
TOP: Integrated Process: Teaching/Learning
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MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
28. The vector reservoir for agents causing viral encephalitis in the United States is:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 954
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
29. Which 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 956
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30. 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. measles.
b. varicella.
c. meningitis.
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 956
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. When caring for the child with Reye syndrome, the priority nursing intervention
should be to:
a. monitor intake and output.
b. prevent skin breakdown.
c. observe for petechiae.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 956
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. A young childs parents call the nurse after their child was bitten by a raccoon in the
woods. The nurses recommendation should be based on which statement?
a. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 955
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. 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. The nurses best response is:
a. Epilepsy is easily treated.
b. Very few children have actual epilepsy.
c. The seizure may or may not mean that your child has epilepsy.
d. Your child has had only one convulsion; it probably wont 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 956
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. Which type of seizure involves both hemispheres of the brain?
a. Focal
b. Partial
c. Generalized
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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.
PTS: 1 DIF: Cognitive Level: Remember REF: 957
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
35. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 958
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
36. 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 childs
behavior during the seizure. Generalized, simple partial, and complex partial seizures all
have clinical manifestations that are observable.
PTS: 1 DIF: Cognitive Level: Understand REF: 958
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
37. An important nursing intervention when caring for a child who is experiencing a
seizure would be to:
a. describe and record the seizure activity observed.
b. restrain the child when seizure occurs to prevent bodily harm.
c. place a tongue blade between the teeth if they become clenched.
d. suction the child during a seizure to prevent aspiration.
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 childs mouth. This may cause injury. To
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prevent aspiration, if possible, the child should be placed on the side, facilitating
drainage.
PTS: 1 DIF: Cognitive Level: Apply REF: 962
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
38. 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. The
most appropriate initial action by the school nurse is to:
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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 965
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
39. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 960
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
40. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin (Dilantin)
may experience a deficiency of:
a. calcium.
b. vitamin C.
c. fat-soluble vitamins.
d. vitamin D and folic acid.
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 965
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
41. 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 968
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
42. The nurse is monitoring a 7-year-old child post-surgical resection of an infratentorial
brain tumor. Which vital sign findings indicate Cushings triad?
a. Increased temperature, tachycardia, tachypnea
b. Decreased temperature, bradycardia, bradypnea
c. Bradycardia, hypertension, irregular respirations
d. Bradycardia, hypotension, tachypnea
ANS: C
Cushings 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 Cushings triad.
PTS: 1 DIF: Cognitive Level: Understand REF: 948
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
43. 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 childs back,
not head, to maintain the desired position.
PTS: 1 DIF: Cognitive Level: Apply REF: 948
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 947
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which are clinical manifestations of increased intracranial pressure (ICP) in infants?
(Select all that apply.)
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia and blurred vision
d. Irritability
e. Distended scalp veins
f. Increased blood pressure
ANS: D, E
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased
ICP in infants. Diplopia and blurred vision is indicative of ICP in children. A high-pitched
cry and a tense or bulging fontanel are characteristics of increased ICP. Increased blood
pressure, common in adults, is rarely seen in children.
PTS: 1 DIF: Cognitive Level: Understand REF: 929
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. An infant with hydrocephalus is hospitalized for surgical placement of a
ventriculoperitoneal shunt. Which interventions should be included in the childs
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 969
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3year-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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 954
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 946
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. 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.)
a. Tachycardia
b. Alteration in pupil size and reactivity
c. Increased motor response
d. Extension or flexion posturing
e. Cheyne-Stokes respirations
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 929
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
ESSAY
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 highestpriority intervention sequencing to the lowest-priority intervention. Provide 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.
CHAPTER 17 Nursing Care of the Child With an Alteration in Sensory Perception/
Disorder of the Eyes or Ears
MULTIPLE CHOICE
1. A young child has an intelligence quotient (IQ) of 45. The nurse should document this
finding as:
a. within the lower limits of the range of normal intelligence.
b. mild cognitive impairment but educable.
c. moderate cognitive impairment but trainable.
d. severe cognitive impairment and completely dependent on others for care.
ANS: C
Moderate cognitively 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 572
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?
a. Achieves a mental age of 5 to 6 years
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b. Achieves a mental age of 8 to 12 years
c. Unable to progress in functional reading or arithmetic
d. Acquires practical skills and useful reading and arithmetic to an eighth-grade level
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 572
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?
a. As young as possible
b. As soon as they have the ability to communicate in some way
c. At age 3 years, when schools are required to provide services
d. At age 5 or 6 years, when schools are required to provide services
ANS: A
The childs 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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 572-573
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?
a. Safety
b. Age appropriateness
c. Ability to provide exercise
d. Ability to teach useful skills
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 574
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection
Control
5. Appropriate interventions to facilitate socialization of the cognitively impaired child
include:
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a. providing age-appropriate toys and play activities.
b. providing peer experiences, such as scouting, when older.
c. avoiding exposure to strangers who may not understand cognitive development.
d. emphasizing 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 575
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 575
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
7. When caring for a newborn with Down syndrome, the nurse should be aware that the
most common congenital anomaly associated with Down syndrome is:
a. hypospadias.
b. pyloric stenosis.
c. congenital heart disease.
d. congenital hip dysplasia.
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 576
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 nurses recommendation should be based on which
statement?
a. Programs like Cub Scouts are inappropriate for children who are mentally retarded.
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 575
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 576
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. These findings
are most suggestive of:
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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 576
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?
a. Hyperflexibility
b. Cutis marmorata
c. Atlantoaxial instability
d. Speckling of iris (Brushfield spots)
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 childs ability to participate in
sports.
PTS: 1 DIF: Cognitive Level: Understand REF: 577
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 childs 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 coolmist 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 childs weight and
growth needs, not age.
PTS: 1 DIF: Cognitive Level: Apply REF: 578
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. The nurse recognizes that
fragile X syndrome is:
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 mental retardation.
d. the most common cause of noninherited mental retardation.
ANS: C
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Fragile X syndrome is the second most common cause of mental retardation after Down
syndrome. Fragile X primarily affects males, 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 578
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 580
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 580
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?
a. 0 dB
b. 10 dB
c. 40 to 50 dB
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d. 100 dB
ANS: A
By definition, 0 dB is the softest sound the normal ear can hear. Ten dB 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 580
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?
a. Absence of the Moro reflex
b. Absence of babbling by age 7 months
c. Lack of eye contact when being spoken to
d. Lack of gesturing to indicate wants after age 15 months
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 581
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 580-581
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
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aids and amplification devices are external devices for enhancing hearing. Auditory
implants do not exist.
PTS: 1 DIF: Cognitive Level: Understand REF: 581
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 lip reading?
a. Speak at an even rate.
b. Exaggerate pronunciation of words.
c. Avoid using facial expressions.
d. Repeat in exactly the same way if 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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 582
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. The nurse should include that the most common cause of hearing impairment in
children is:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 583-584
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?
a. Being involved in immunization clinics for children
b. Assessing a newborn for hearing loss
c. Answering parents questions about hearing aids
d. Participating in hearing screening in the community
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 584
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 a 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 584
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 585
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?
a. Excessive rubbing of the eyes
b. Rapid lateral movement of the eyes
c. Delay in speech development
d. Lack of interest in casual conversation with peers
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 584
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 585
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 nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 586 | 589
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 daughters 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 586 | 589
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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). The nurse
should:
a. apply a Fox shield.
b. instruct the adolescent to apply ice for 24 hours.
c. have adolescent rest with eye closed and ice applied.
d. notify parents that 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 586
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. Cats 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 cats 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 589
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 sisters 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 sisters 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 sisters
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 580
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 572 | 576
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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 578
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?
a. Maintain a structured routine and keep stimulation to a minimum.
b. Place child in a room with a roommate of the same age.
c. Maintain frequent touch and eye contact with the child.
d. Take the child frequently to the playroom to play with other children.
ANS: A
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 593
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 591
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.)
a. High arched narrow palate
b. Protruding tongue
c. Long, slender fingers
d. Transverse palmar crease
e. Hypertonic muscle tone
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 577
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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3. 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 childs facial appearance. An
eye patch is in place, and the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 590
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is instructing a nursing assistant on techniques to facilitate lip reading 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 lip reading 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 lip reading.
CHAPTER 18 Nursing Care of the Child With an Alteration in Gas Exchange/
Respiratory Disorder
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.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 707
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?
a. Dyspnea
b. Tachypnea
c. Hypopnea
d. Orthopnea
ANS: A
Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is
too shallow. Orthopnea is difficulty breathing except in upright position.
PTS: 1 DIF: Cognitive Level: Remember REF: 709
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?
a. They are safer.
b. They are less expensive.
c. Respiratory secretions are dried.
d. A more comfortable environment is produced.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 708
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?
a. Avoid using for more than 3 days.
b. Keep drops to use again for nasal congestion.
c. Administer drops until nasal congestion subsides.
d. Administer drops after feedings and at bedtime.
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
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can have a rebound effect after 3 days of use. Drops administered before feedings are
more helpful.
PTS: 1 DIF: Cognitive Level: Apply REF: 709
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?
a. Give tepid water baths to reduce fever.
b. Encourage food intake to maintain caloric needs.
c. Have child wear heavy clothing to prevent chilling.
d. Give small amounts of favorite fluids frequently to prevent dehydration.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 710
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 714
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. It is generally recommended that a child with acute streptococcal pharyngitis can
return to school:
a. when sore throat is better.
b. if no complications develop.
c. after taking antibiotics for 24 hours.
d. after taking antibiotics for 3 days.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 715
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
8. A child is diagnosed with influenza, probably type A disease. Management includes
which recommendation?
a. Clear liquid diet for hydration
b. Aspirin to control fever
c. Amantadine hydrochloride (Symmetrel) to reduce symptoms
d. Antibiotics to prevent bacterial infection
ANS: C
Amantadine hydrochloride may reduce symptoms related to influenza A if administered
within 24 to 48 hours of onset. It is ineffective against type B or C. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 717
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
9. Chronic otitis media with effusion (OME) is differentiated from acute otitis media
(AOM) because it is usually characterized by:
a. a fever as high as 40 C (104 F).
b. severe pain in the ear.
c. nausea and vomiting.
d. a feeling of fullness in the ear.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 718
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 719
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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. Trimethoprimsulfamethoxazole (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.
PTS: 1 DIF: Cognitive Level: Apply REF: 718
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
12. An infants 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 supine position.
ANS: A
Eliminating tobacco smoke from the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 719
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 childs throat by
using a tongue depressor might precipitate which symptom or condition?
a. Inspiratory stridor
b. Complete obstruction
c. Sore throat
d. Respiratory tract infection
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 721
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 721
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 nurses rationale for this action is
described primarily in which statement?
a. Mothers of hospitalized toddlers often experience guilt.
b. The mothers presence will reduce anxiety and ease childs respiratory efforts.
c. Separation from mother is a major developmental threat at this age.
d. The mother can provide constant observations of the childs respiratory efforts.
ANS: B
The familys presence will decrease the childs 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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 723
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 723
TOP: Integrated Process: Nursing Process: Diagnosis
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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?
a. Every year for all children older than 2 years
b. Every year for all children older than 10 years
c. Every 2 years for all children starting at age 1 year
d. Periodically for children who reside in high-prevalence regions
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 729
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 730
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?
a. Gagging
b. Coughing
c. Pulse over 100 beats/min
d. Inability to speak
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 732
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. Nursing actions should include:
a. forcing fluids.
b. monitoring pulse oximetry.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 734
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 childs care?
a. Monitor pulse oximetry.
b. Monitor arterial blood gases.
c. Administer oxygen if respiratory distress develops.
d. Administer oxygen if childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 735
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A nurse is admitting an infant with asthma. The nurse understands that asthma in
infants is usually triggered by:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 737
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?
a. There is heightened airway reactivity.
b. There is decreased resistance in the airway.
c. The single cause of asthma is an allergic hypersensitivity.
d. It is inherited.
ANS: A
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 737
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?
a. Nonproductive cough, wheezing
b. Fever, general malaise
c. Productive cough, rales
d. Stridor, substernal retractions
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 738
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?
a. Cough
b. Osteoporosis
c. Slowed growth
d. Cushing syndrome
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 739-740
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?
a. Liquefy secretions.
b. Dilate the bronchioles.
c. Reduce inflammation of the lungs.
d. Reduce infection.
ANS: B
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 740
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?
a. Soccer
b. Running
c. Swimming
d. Basketball
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.
Exercise-induced bronchospasm is more common in sports that involve endurance, such
as soccer. Prophylaxis with medications may be necessary.
PTS: 1 DIF: Cognitive Level: Apply REF: 740
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 741
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?
a. If it is present in a child, both parents are carriers of this defective gene.
b. It is inherited as an autosomal dominant trait.
c. It is a genetic defect found primarily in non-Caucasian population groups.
d. There is a 50% chance that siblings of an affected child also will be affected.
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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 747
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?
a. Meconium ileus
b. History of poor intestinal absorption
c. Foul-smelling, frothy, greasy stools
d. Recurrent pneumonia and lung infections
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 747
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?
a. Sweat chloride test, stool for fat, chest radiograph films
b. Stool test for fat, gastric contents for hydrochloride, chest radiograph films
c. Sweat chloride test, bronchoscopy, duodenal fluid analysis
d. Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa
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.
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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.
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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?
a. Before chest physiotherapy (CPT)
b. After CPT
c. Before receiving 100% oxygen
d. After receiving 100% oxygen
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 750
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 750
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). Nursing
considerations should include to:
a. not administer pancreatic enzymes if child is receiving antibiotics.
b. decrease dose of pancreatic enzymes if child is having frequent, bulky stools.
c. administer pancreatic enzymes between meals if at all possible.
d. pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food
taken at the beginning of a meal.
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 child is having frequent, bulky stools.
Enzymes should be given just before meals and snacks.
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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.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 757
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.
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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.
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c. reassessment of child after 50 cycles of compression and ventilation.
d. reassessment of 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.
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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).
a. 1
b. 4
c. 8
d. 12
ANS: A
The Heimlich maneuver is recommended for airway obstruction in children older than 1
year. Younger than 1 year, back blows and chest thrusts are administered. The Heimlich
maneuver can be used in children older than 1 year.
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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.
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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?
a. I will record the average of the readings.
b. I should be sitting comfortably when I perform the readings.
c. I will record the readings at the same time every day.
d. I will repeat the routine two times.
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
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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.
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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 childs 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.
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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 4872 hours
after the test?
a. 5 mm
b. 10 mm
c. 15 mm
d. 20 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 5 mm. Children younger than 4
years of age with: (a) 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 highprevalence (TB) regions of the world are positive when the induration is 10 mm. Children
4 years of age or older without any risk factors are positive when the induration is 20
mm.
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TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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
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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.
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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 childs care? (Select all that
apply.)
a. Place in a mist tent.
b. Administer antibiotics.
c. Administer cough syrup.
d. Encourage 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.
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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 childs 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.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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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
childs 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.
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SHORT ANSWER
1. A nurse is interpreting the results of a childs 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.
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ESSAY
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.
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d. Use the head tiltchin 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
CHAPTER 19 Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular
Disorder
MULTIPLE CHOICE
1. A chest radiograph film is ordered for a child with suspected cardiac problems. The
childs parent asks the nurse, What will the radiograph show about the heart? The nurses
response should be based on knowledge that the x-ray film will show:
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.
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2. The nurse is assessing a child after a cardiac catheterization. Which complication
should the nurse be assessing for?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Heart failure
d. Rapidly increasing blood pressure
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.
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3. Jos is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching
should be:
a. directed at his parents because he is too young to understand.
b. detailed in regard to the actual procedures so he will know what to expect.
c. done several days before the procedure so that he will be prepared.
d. adapted to his level of development so that he can understand.
ANS: D
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Preoperative teaching should always be directed at the childs 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.
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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 childs leg will have to be maintained in a straight position for approximately 4 hours.
Younger children can be held in the parents 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.
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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. The most appropriate initial nursing action is to:
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.
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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.
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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.
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7. Surgical closure of the ductus arteriosus would:
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.
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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.
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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
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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.
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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.
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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?
a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion
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 bodys 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.
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12. Which is a clinical manifestation of the systemic venous congestion that can occur
with heart failure?
a. Tachypnea
b. Tachycardia
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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.
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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)?
a. It decreases edema.
b. It decreases cardiac output.
c. It increases heart size.
d. It increases venous pressure.
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.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
14. A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor.
Which drug should the nurse be administering?
a. Captopril (Capoten)
b. Furosemide (Lasix)
c. Spironolactone (Aldactone)
d. Chlorothiazide (Diuril)
ANS: A
Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the
action of aldosterone. Chlorothiazide works on the distal tubules.
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Therapy
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.
a. 60
b. 70
c. 90
d. 100
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
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below 90 to 110 beats/min is the determination for not giving a digoxin dose to infants
and young children.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
a. 60
b. 70
c. 90 to 110
d. 110 to 120
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. 60 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 836
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 839
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
18. The parents of a young child with heart failure tell the nurse that they are nervous
about giving digoxin (Lanoxin). The nurses response should be based on which
statement?
a. It is a safe, frequently used drug.
b. It is difficult to either overmedicate or undermedicate with digoxin.
c. Parents lack the expertise necessary to administer digoxin.
d. Parents must learn specific, important guidelines for administration of digoxin.
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 839
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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 infants 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 838-839
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:
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 childs diet should be supplemented with this electrolyte. With this type
of diuretic, potassium must be monitored and supplemented as needed.
PTS: 1 DIF: Cognitive Level: Understand REF: 840
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
21. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The
nurses first action should be to:
a. assess for neurologic defects.
b. place the child in the knee-chest position.
c. begin cardiopulmonary resuscitation.
d. prepare family for imminent death.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 841-842
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 841
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 nurses reply should be
based on which statement?
a. Child needs opportunities to play with peers.
b. Child needs to understand that peers activities are too strenuous.
c. Parents can meet all of the childs 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 843
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?
a. Unfamiliar equipment should not be shown.
b. Let child hear the sounds of an ECG monitor.
c. Avoid mentioning postoperative discomfort and interventions.
d. Explain that an endotracheal tube will not be needed if the surgery goes well.
ANS: B
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 845
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?
a. Keep child warm with blankets.
b. Apply a hypothermia blanket.
c. Record temperature on nurses notes.
d. Report findings to physician.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 846
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 846
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. Which should the nurse do if
evidence is found of cardiac tamponade?
a. Increase analgesia.
b. Apply warming blankets.
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c. Immediately report this to physician.
d. Encourage child to cough, turn, and breathe deeply.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 846
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 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 846
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 848
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?
a. Osler nodes
b. Janeway lesions
c. Subcutaneous nodules
d. Aschoff nodes
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 848
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. The primary nursing intervention to prevent bacterial endocarditis is to:
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 childs dentist should be aware of the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 848
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 849
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?
a. Polyarthritis
b. Osler nodes
c. Janeway spots
d. Splinter hemorrhages of distal third of nails
ANS: A
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 850
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 849
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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 preventionprimarily 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 849-850
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, the nurse should
explain that cardiovascular disease can be prevented by high levels of:
a. cholesterol.
b. triglycerides.
c. low-density lipoproteins (LDLs).
d. high-density lipoproteins (HDLs).
ANS: D
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 851
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 856
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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 859
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. One of the
most frequent causes of hypovolemic shock in children is:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 860
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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?
a. Neurogenic
b. Cardiogenic
c. Hypovolemic
d. Anaphylactic
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 862-863
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?
a. Thirst
b. Irritability
c. Apprehension
d. Confusion and somnolence
ANS: D
Confusion and somnolence are beginning signs of decompensated shock. Thirst,
irritability, and apprehension are signs of compensated shock.
PTS: 1 DIF: Cognitive Level: Understand REF: 861
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 864
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)
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 862
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
44. Clinical manifestations of toxic shock syndrome include:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 864
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 cant 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 821
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?
a. Organize nursing activities to allow for uninterrupted sleep.
b. Allow the infant to sleep through feedings during the night.
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c. Wait for the infant to cry to show definite signs of hunger.
d. Discourage parents from rocking the infant
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 infants 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 839
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. c.
CHAPTER 20 Nursing Care of the Child With an Alteration in Bowel Elimination/
Gastrointestinal Disorder
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 763
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 792
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?
a. Isotonic dehydration
b. Hypotonic dehydration
c. Hypertonic dehydration
d. All types of dehydration in infants and small children
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 767
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?
a. Isotonic
b. Isosmotic
c. Hypotonic
d. Hypertonic
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 isotonic
dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water
deficit, leaving the serum hypotonic.
PTS: 1 DIF: Cognitive Level: Understand REF: 767
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. Weight gain
b. Bradycardia
c. Poor skin turgor
d. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 767
TOP: Integrated Process: Nursing Process: Assessment
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 772
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 772
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 775
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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 775
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 775
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
childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 775-776
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. Therapeutic management of this child should
begin with:
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 776
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 nurses
response should be based on knowledge that this drug is:
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 777
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. The nurse should
suspect that the constipation is most likely caused by:
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 778
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
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15. Which is a high-fiber food that the nurse should recommend for a child with chronic
constipation?
a. Popcorn
b. Pancakes
c. Muffins
d. Ripe bananas
ANS: A
Popcorn is 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 779-780
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?
a. Daily enemas
b. Low-fiber diet
c. Permanent colostomy
d. Surgical removal of affected section of bowel
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 781
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. The enema solution should be:
a. tap water.
b. normal saline.
c. oil retention.
d. phosphate preparation.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 781
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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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 childs 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 childs 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 781
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 782
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 has 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 783
TOP: Integrated Process: Teaching/Learning
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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. The purpose of this is to:
a. prevent reflux.
b. prevent hematemesis.
c. reduce gastric acid production.
d. increase gastric acid production.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 783
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 785
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?
a. Bradycardia
b. Anorexia
c. Sudden relief from pain
d. Decreased abdominal distention
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 786
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?
a. Place in Trendelenburg position.
b. Allow to assume position of comfort.
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c. Apply moist heat to the abdomen.
d. Administer a saline enema to cleanse bowel.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 787
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 788
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 Crohns the inflammatory process involves the whole GI tract.
b. There is no difference between the two diseases.
c. The inflammation with Crohns 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 789
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?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 790
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
28. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child
with a peptic ulcer to:
a. eradicate Helicobacter pylori.
b. coat gastric mucosa.
c. treat epigastric pain.
d. reduce gastric acid production.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 793
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 795
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
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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.
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TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
31. The best chance of survival for a child with cirrhosis is:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 798
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, 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 798-799
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. Initial therapeutic approach to the mother should
be:
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 babys need for mothering.
d. recognizing that negative feelings toward the child continue throughout childhood.
ANS: B
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For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse
must place emphasize not only the infants 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 nurses actions should convey to the parents that the infant is a precious
human being. The nurse emphasizes the childs normalcy and helps the mother recognize
the childs uniqueness. Maternal-infant attachment was not negatively affected at age 1
year.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
34. Caring for the newborn with a cleft lip and palate before surgical repair includes:
a. gastrostomy feedings.
b. keeping infant in near-horizontal position during feedings.
c. allowing little or no sucking.
d. providing satisfaction of sucking needs.
ANS: D
Using special or modified nipples for feeding techniques helps meet the infants sucking
needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with
the infants head in an upright position. The child requires both nutritive and nonnutritive
sucking.
PTS: 1 DIF: Cognitive Level: Apply REF: 801
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.
Nursing interventions should include:
a. giving medication to suppress lactation.
b. encouraging and helping mother to breastfeed.
c. teaching mother to feed breast milk by gavage.
d. recommending use of a breast pump to maintain lactation until infant can suck.
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 infants 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 801
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. Important aspects of
this infants postoperative care include:
a. arm restraints, postural drainage, mouth irrigations.
b. cleansing the suture line, supine and side-lying positions, arm restraints.
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c. mouth irrigations, prone position, cleansing suture line.
d. supine and side-lying positions, postural drainage, arm restraints.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 802
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 802
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. Nursing
care should include:
a. elevating the head but give nothing by mouth.
b. elevating the head for feedings.
c. feeding glucose water only.
d. avoiding 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.
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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
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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.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40. Pyloric stenosis can best be described as:
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.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 806
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?
a. Abdominal rigidity and pain on palpation
b. Rounded abdomen and hypoactive bowel sounds
c. Visible peristalsis and weight loss
d. Distention of lower abdomen and constipation
ANS: C
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 808
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
43. An infant with pyloric stenosis experiences excessive vomiting that can result in:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 808
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
44. Invagination of one segment of bowel within another is 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 809
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 diagnostictherapeutic care plan. The first action would be to report the normal stool to the
practitioner.
PTS: 1 DIF: Cognitive Level: Apply REF: 809
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 814
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. Nursing care should include:
a. preparing family for impending death.
b. teaching family signs of central venous catheter infection.
c. teaching family how to calculate caloric needs.
d. securing 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 815
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 physicians 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
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A newborn with a gastroschisis performed the day before will require bowel
decompression with an NG tube to low wall intermittent suction. The nurses 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 physicians prescription was to
have the NG tube to low wall intermittent suction so the tube cannot be placed to gravity
drainage.
PTS: 1 DIF: Cognitive Level: Apply REF: 807
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 nurses 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 cant 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 793
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?
a. To rule out lactose intolerance
b. To rule out celiac disease
c. To rule out sensitivity to high sugar content
d. To rule out peptic ulcer disease
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 784
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
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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 childs developmental and physiologic readiness.
PTS: 1 DIF: Cognitive Level: Apply REF: 812
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 mothers 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 795
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
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bronchi, especially when intraabdominal 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 804
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.)
a. NPO for 24 hours
b. Administration of analgesics for pain
c. Ice bag to the incisional area
d. IV fluids continued until tolerating PO
e. Clear liquids as the first feeding
ANS: B, D, E
Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear
liquids 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 809
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 not white rice. Raw fruits, especially those with skins or
seeds, other than ripe banana or avocado are high in fiber.
PTS: 1 DIF: Cognitive Level: Understand REF: 780
TOP: Integrated Process: Teaching/Learning
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MSC: Area of Client Needs: Health Promotion and Maintenance
SHORT ANSWER
1. A child has an NG tube to continuous low intermittent suction. The physicians
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.
CHAPTER 21 Nursing Care of the Child With an Alteration in Urinary Elimination/
Genitourinary Disorder
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 908
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
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in the urine demonstrates abnormal glomerular permeability, it is not a measure of
filtration rate.
PTS: 1 DIF: Cognitive Level: Understand REF: 904
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?
a. Fever with a positive blood culture
b. Proteinuria and edema
c. Oliguria and hypertension
d. Anemia and thrombocytopenia
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).
PTS: 1 DIF: Cognitive Level: Analyze REF: 906
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?
a. Increased fluid intake
b. Short urethra in young girls
c. Prostatic secretions in males
d. Frequent emptying of the bladder
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 908
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 910
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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6. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects
which finding in this newborn?
a. Absence of a urethral opening is noted.
b. Penis appears shorter than usual for age.
c. The urethral opening is along the dorsal surface of the penis.
d. The urethral opening is along the ventral surface of the penis.
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. Urethral
opening along ventral surface of penis is known as epispadias.
PTS: 1 DIF: Cognitive Level: Understand REF: 912
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 912
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 914
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 914
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 914
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 914
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?
a. Prevent infection.
b. Stimulate appetite.
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c. Detect evidence of edema.
d. Ensure compliance with prophylactic antibiotic therapy.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 914
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 highsalt ones) in an attempt to provide nutritionally complete meals.
PTS: 1 DIF: Cognitive Level: Understand REF: 914
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 -hemolytic streptococcus. Acute
glomerulonephritis usually follows streptococcal pharyngitis and is not associated with
renal vascular disorders or genitourinary tract structural anomalies.
PTS: 1 DIF: Cognitive Level: Understand REF: 915
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. A child is admitted with acute glomerulonephritis. The nurse should expect the
urinalysis during this acute phase to show:
a. bacteriuria, hematuria.
b. hematuria, proteinuria.
c. bacteriuria, increased specific gravity.
d. proteinuria, decreased specific gravity.
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 915
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. The nurses best response should be that the:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 916
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. This is most likely the result of:
a. poor appetite.
b. increased potassium intake.
c. reduction of edema.
d. restriction to bed rest.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 916
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 childs diet.
b. Your childs diet will need an increased amount of protein.
c. You will need to avoid adding salt to your childs food.
d. Your childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 916
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 915
TOP: Integrated Process: Nursing Process: Nursing Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. The nurse is admitting a child with a Wilms tumor. Which is the initial assessment
finding associated with this tumor?
a. Abdominal swelling
b. Weight gain
c. Hypotension
d. Increased urinary output
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 917
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. Which is the most common cause of acute renal failure in children?
a. Pyelonephritis
b. Tubular destruction
c. Urinary tract obstruction
d. Severe dehydration
ANS: D
The most common cause of acute renal failure in children is dehydration or other causes
of 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 919
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. 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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 919
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 920
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 921
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. 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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 921
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 922
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. One of the clinical manifestations of chronic renal failure is uremic frost. Which best
describes this term?
a. Deposits of urea crystals in urine
b. Deposits of urea crystals on skin
c. Overexcretion of blood urea nitrogen
d. Inability of body to tolerate cold temperatures
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 922
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. Calcium carbonate is given with meals to a child with chronic renal disease. The
purpose of this is to:
a. prevent vomiting.
b. bind phosphorus.
c. stimulate appetite.
d. increase absorption of fat-soluble vitamins.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 922
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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29. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 922
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
30. The nurse is caring for an adolescent who has just started dialysis. The child seems
always angry, hostile, or depressed. The nurse should recognize that this is most likely
related to:
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 childs age, not neurologic or physiologic manifestations of the dialysis.
Feelings of anger, hostility, and depression are functions of the childs 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 923
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
31. Which 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 923
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. Which statement is descriptive of renal transplantation in children?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 925
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. 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?
a. WBC <1; specific gravity 1.008
b. WBC <2; specific gravity 1.025
c. WBC >2; specific gravity 1.016
d. WBC >2; specific gravity 1.030
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 907
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. 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 wont 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 925
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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35. 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. Were 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 916 | 923
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
36. 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 potassium sparing 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 920
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 909
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.)
a. Apples
b. Bananas
c. Cheese
d. Carrot sticks
e. Strawberries
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 916
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 914
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.)
a. Clear liquids in the morning before the procedure
b. Cathartic in the evening before the procedure
c. Soapsuds enema the morning of the procedure
d. Insertion of a Foley catheter before the procedure
e. Teaching with regard to insertion of an intravenous catheter before the procedure
ANS: B, C, E
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 905
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.
CHAPTER 22 Nursing Care of the Child With an Alteration in Mobility/Neuromuscular
or Musculoskeletal Disorder
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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1051
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?
a. Hypocalcemia
b. Decreased metabolic rate
c. Positive nitrogen balance
d. Increased production of stress hormones
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 1051
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?
a. Venous stasis
b. Increased vasopressor mechanism
c. Normal distribution of blood volume
d. Increased efficiency of orthostatic neurovascular reflexes
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1051
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1051
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 childs
parents, the most appropriate, immediate action by the school nurse is to:
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
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parental permission for administration of acetaminophen or aspirin are not immediate
priorities. The application of ice can reduce the severity of the injury.
PTS: 1 DIF: Cognitive Level: Apply REF: 1056
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1057
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1057
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?
a. Cheaper
b. Dries rapidly
c. Molds closely to body parts
d. Smooth exterior
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 1060
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?
a. Swelling of the fingers is to be expected for the next 48 hours.
b. Immobilize the shoulder to decrease pain in the arm.
c. Allow the affected limb to hang down for 1 hour each day.
d. Elevate casted arm when resting and when sitting up.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1060
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 patients 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 patients
limb balanced are not reasons for using the palms of the hand rather than the fingers when
handling a wet cast.
PTS: 1 DIF: Cognitive Level: Understand REF: 1060
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 1060
TOP: Integrated Process: Nursing Process: Assessment
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1062
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 Russells 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 muscles 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1063
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. Which is a type of skin traction with 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-Calv-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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1063
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 shortterm immobilization, preoperatively with dislocated hips, for correcting contractures, or
for bone deformities such as Legg-Calv-Perthes disease.
PTS: 1 DIF: Cognitive Level: Understand REF: 1063
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-Calv-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-Calv-Perthes disease is an emergency condition; immediate reporting is
indicated. The findings should be documented with ongoing assessment.
PTS: 1 DIF: Cognitive Level: Apply REF: 1065
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1065
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1071
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?
a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1072
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-Calv-Perthes disease. Nursing
considerations should include which action?
a. Encouraging normal activity for as long as is possible
b. Explaining the cause of the disease to the child and family
c. Preparing the child and family for long-term, permanent disabilities
d. Teaching the family the care and management of the corrective appliance
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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 nonweight bearing, which helps reduce inflammation and restore
motion. Legg-Calv-Perthes 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 childs age at onset.
PTS: 1 DIF: Cognitive Level: Apply REF: 1075
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1076
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?
a. Newborn period
b. When child starts to walk
c. Preadolescent growth spurt
d. Adolescence
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1076-1077
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 Luque-rod segmental spinal
instrumentation procedure. Which consideration should the nurse include?
a. Nasogastric intubation and urinary catheter may be required.
b. Ambulation will not be allowed for up to 3 months.
c. Surgery eliminates the need for casting and bracing.
d. Discomfort can be controlled with nonpharmacologic methods.
ANS: A
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Luque-rod segmental spinal instrumentation is a surgical procedure. Nasogastric
intubation 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1078
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The nurse is taking care of a 10-year-old child who has osteomyelitis. Which
treatment plan is considered the primary method of treating osteomyelitis?
a. Joint replacement
b. Bracing and casting
c. Intravenous antibiotic therapy
d. Long-term corticosteroid therapy
ANS: C
Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus
aureus. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and
long-term corticosteroid therapy are not indicated for infectious processes.
PTS: 1 DIF: Cognitive Level: Understand REF: 1080
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
25. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1081
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. 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 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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1081
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. An adolescent with osteosarcoma is scheduled for a leg amputation in 2 days. The
nurses 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 childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1082
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
28. 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 anti-inflammatory 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 second-line therapy for JIA.
PTS: 1 DIF: Cognitive Level: Understand REF: 1085
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
29. 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.
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ANS: C
The management of JIA is primarily pharmacologic. The family should be instructed
regarding administration of medications and the value of 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1086
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
30. 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 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1066
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
31. 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?
a. We will be very careful handling the baby.
b. We will lift the baby by the buttocks when diapering.
c. Were glad there is a cure for this disorder.
d. We will schedule follow-up appointments as instructed.
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,
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 1074
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
32. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1082
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.)
a. Positive Ortolani click
b. Unequal gluteal folds
c. Negative Babinski sign
d. Trendelenburg sign
e. Telescoping of the affected limb
f. Lordosis
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1069
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. 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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1083
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1085
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. 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.)
a. Instructions to avoid exposure to sunlight
b. Teaching about body changes associated with SLE
c. Preparation for home schooling
d. Restricted activity
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 sunresistant 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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 1087
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. 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.
CHAPTER 23 Nursing Care of the Child With an Alteration in Tissue Integrity/
Integumentary Disorder
MULTIPLE CHOICE
1. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1011
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. 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
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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.
PTS: 1 DIF: Cognitive Level: Remember REF: 1011
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1011
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. 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?
a. Slowly pour hydrogen peroxide over wound.
b. 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.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1015
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. A child steps on a nail and sustains a puncture wound of the foot. Which is the most
appropriate method for cleansing this wound?
a. Wash wound thoroughly with chlorhexidine.
b. Wash wound thoroughly with povidone-iodine.
c. Soak foot in warm water and soap.
d. Soak foot in solution of 50% hydrogen peroxide and 50% water.
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 1016
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1017
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the
nurse what will happen to their childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1018
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. Cellulitis is 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 1018
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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9. The nurse is conducting a staff in-service on appearance of childhood skin conditions.
Lymphangitis (streaking) is frequently seen in which condition?
a. Cellulitis
b. Folliculitis
c. Impetigo contagiosa
d. Staphylococcal scalded skin
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1018
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1019
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. 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
numberincluding surgical removal, electrocautery, curettage, cryotherapy, caustic
solutions, x-ray treatment, and laser therapiesis used. Vaccination is prophylaxis for warts
and is not a treatment. Corticosteroids and specific antibiotic therapy are not effective in
the treatment of warts.
PTS: 1 DIF: Cognitive Level: Apply REF: 1019
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. 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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1019
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. 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?
a. Corticosteroids
b. Oral griseofulvin
c. Oral antiviral agent
d. Topical and/or systemic antibiotic
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1019
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
14. Tinea capitis (ringworm), frequently found in schoolchildren, is caused by a(n):
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1020
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection.
The nurse should expect that therapeutic management for this child includes:
a. administering oral griseofulvin.
b. administering topical or oral antibiotics.
c. applying topical sulfonamides.
d. applying Burow solution compresses to affected area.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1020
TOP: Integrated Process: Nursing Process: Implementation
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MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
16. Parents tell the nurse that their child keeps scratching the areas where he has poison
ivy. The nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1022
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. The nurse is taking care of a child with scabies. Which primary clinical manifestation
should the nurse expect to assess with this disease?
a. Edema
b. Redness
c. Pruritus
d. Maceration
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1024 | 1026
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1027
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
19. 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.
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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 childs hair short; lice infest short hair as well as long. It increases the childs
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1027
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. The management of a child who has just been stung by a bee or wasp should include
the application of:
a. cool compresses.
b. warm compresses.
c. antibiotic cream.
d. corticosteroid cream.
ANS: A
Bee or wasp stings are initially treated by carefully removing stinger, cleansing with soap
and water, applying cool compresses, and using common household agents such as lemon
juice or a paste made with aspirin and baking soda. Warm compresses are avoided.
Antibiotic cream is unnecessary unless a secondary infection occurs. Corticosteroid
cream is not part of the initial therapy. If a severe reaction occurs, systemic
corticosteroids may be indicated.
PTS: 1 DIF: Cognitive Level: Apply REF: 1025
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. A father calls the clinic nurse because his 2-year-old child was bitten by a black
widow spider. The nurse should advise which to the father?
a. Apply warm compresses.
b. Carefully scrape off stinger.
c. Take child to emergency department.
d. Apply a thin layer of corticosteroid cream.
ANS: C
The venom of the black widow spider has a neurotoxic effect. The father should take the
child to the emergency department for treatment with antivenin and muscle relaxants as
needed. Warm compresses increase the circulation to the area and facilitate the spread of
the venom. The black widow spider does not have a stinger. Corticosteroid cream will
have no effect on the venom.
PTS: 1 DIF: Cognitive Level: Apply REF: 1025
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A mother calls the emergency department nurse because her child was stung by a
scorpion. The nurse should recommend:
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a. administering an antihistamine.
b. cleansing area with soap and water.
c. keeping the child quiet and coming to the emergency department.
d. removing the stinger and applying cool compresses.
ANS: C
Venomous species of scorpions inject venom that contains hemolysins, endotheliolysins,
and neurotoxins. The absorption of the venom is delayed by keeping the child quiet and
the involved area in a dependent position. Antihistamines are not effective against
scorpion venom. The wound will have intense local pain. Transport to the emergency
department is indicated.
PTS: 1 DIF: Cognitive Level: Analyze REF: 1026
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. Rocky Mountain spotted fever is caused by the bite of a:
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1026
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
24. The school nurse is conducting a class for school-age children on Lyme disease.
Which is characteristic of Lyme disease?
a. Difficult to prevent
b. Treated with oral antibiotics in stages 1, 2, and 3
c. Caused by a spirochete that enters the skin through a tick bite
d. Common in geographic areas where the soil contains the mycotic spores that cause the
disease
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 tickinfested areas with caution. Light-colored clothing should be worn to identify ticks easily.
Long-sleeved 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1029
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
25. 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. This is most likely caused by:
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 1032
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. The nurse is teaching a class on preventing diaper rash in newborns to a group of new
parents. Which statement made by a parent indicates a correct understanding of the
teaching?
a. I should cleanse my infants skin with a commercial diaper wipe every time I change
the diaper.
b. If my infants buttocks become slightly red, I will expose the skin to air.
c. I should wash my infants buttocks with soap before applying a thin layer of oil.
d. I will apply baby oil and powder to the creases in my infants buttocks.
ANS: B
Slightly irritated skin can be exposed to air, not heat, to dry completely. Overwashing or
cleansing the skin every diaper change with commercial wipes should be avoided. The
skin should be thoroughly dried after washing. Application of oil does not create an
effective barrier. Baby powder should not be used because of the danger of aspiration.
PTS: 1 DIF: Cognitive Level: Apply REF: 1032-1033
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. Which prescribed treatment should the nurse plan to implement for a child with
psoriasis?
a. Antihistamines
b. Oral antibiotics
c. Topical application of calamine lotion
d. Tar and exposure to sunlight and ultraviolet light
ANS: D
Psoriasis is treated with tar preparations and exposure to ultraviolet B light or natural
sunlight. Antihistamines, oral antibiotics, and topical application of calamine lotion are
not effective in psoriasis.
PTS: 1 DIF: Cognitive Level: Apply REF: 1031
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
28. Atopic dermatitis (eczema) in the infant is:
a. easily cured.
b. worse in humid climates.
c. associated with upper respiratory tract infections.
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d. associated with allergy with a hereditary tendency.
ANS: D
Atopic dermatitis is a type of pruritic eczema that usually begins during infancy and is
associated with allergy with a hereditary tendency. Atopic dermatitis can be controlled
but not cured. Manifestations of the disease are worse when environmental humidity is
lower. Atopic dermatitis is not associated with respiratory tract infections.
PTS: 1 DIF: Cognitive Level: Understand REF: 1032
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
29. Nursing care of the infant with atopic dermatitis focuses on:
a. feeding a variety of foods.
b. keeping lesions dry.
c. preventing infection.
d. using fabric softener to avoid rough cloth.
ANS: C
The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to
new lesions and secondary infection. The infants nails should be kept short and clean and
have no sharp edges. In periods of irritability, these children tend to have a decreased
appetite. The restriction of hyperallergenic foods, such as milk, dairy products, peanuts,
and eggs, may make adequate nutrition a challenge with these children. Wet soaks and
compresses are used to keep the lesions moist and minimize the pruritus. Fabric softener
should be avoided because of the irritant effects of some of its components.
PTS: 1 DIF: Cognitive Level: Apply REF: 1033
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1036
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
31. 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.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1037
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
32. A child experiences frostbite of the fingers after prolonged exposure to the cold.
Which intervention should the nurse implement first?
a. Rapid rewarming of the fingers by placing in warm water
b. Placing the hand in cool water
c. Slow rewarming by wrapping in warm cloth
d. Using an ice pack to keep cold until medical intervention is possible
ANS: A
Rapid rewarming is accomplished by immersing the part in well-agitated water at 37.8 to
42.2 C (100 to 108 F). The frostbitten area should be rewarmed as soon as possible to
avoid further tissue damage. Rapid rewarming results in less tissue necrosis than slow
thawing.
PTS: 1 DIF: Cognitive Level: Apply REF: 1048
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. Which best describes a full-thickness (third-degree) burn?
a. Erythema and pain
b. Skin showing erythema followed by blister formation
c. Destruction of all layers of skin evident with extension into subcutaneous tissue
d. Destruction injury involving underlying structures such as muscle, fascia, and bone
ANS: C
A third-degree, or full-thickness, burn is a serious injury that involves the entire
epidermis and dermis and extends into the subcutaneous tissues. Erythema and pain are
characteristic of a first-degree, or superficial, burn. Erythema with blister formation is
characteristic of a second-degree, or partial-thickness, burn. A fourth-degree burn is a
full-thickness burn that also involves underlying structures such as muscle, fascia, and
bone.
PTS: 1 DIF: Cognitive Level: Understand REF: 1039
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. A child is admitted with extensive burns. The nurse notes that there are burns on the
childs lips and singed nasal hairs. The nurse should suspect that the child has a(n):
a. chemical burn.
b. inhalation injury.
c. electrical burn.
d. hot-water scald.
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ANS: B
Evidence of an inhalation injury is burns of the face and lips, singed nasal hairs, and
laryngeal edema. Clinical manifestation may be delayed for up to 24 hours. Chemical
burns, electrical burns, and those associated with hot-water scalds would not cause singed
nasal hair.
PTS: 1 DIF: Cognitive Level: Understand REF: 1040
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
35. Which explains physiologically the edema formation that occurs with burns?
a. Vasoconstriction
b. Decreased capillary permeability
c. Increased capillary permeability
d. Decreased hydrostatic pressure within capillaries
ANS: C
With a major burn, an increase in capillary permeability occurs, allowing plasma
proteins, fluids, and electrolytes to be lost. Maximal edema in a small wound occurs
about 8 to 12 hours after injury. In larger injuries, the maximal edema may not occur until
18 to 24 hours. Vasoconstriction, decreased capillary permeability, and decreased
hydrostatic pressure within capillaries are not physiologic mechanisms for edema
formation in burn patients.
PTS: 1 DIF: Cognitive Level: Analyze REF: 1040
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
36. The most immediate threat to life in children with thermal injuries is:
a. shock.
b. anemia.
c. local infection.
d. systemic sepsis.
ANS: A
The immediate threat to life in children with thermal injuries is airway compromise and
profound shock. Anemia is not of immediate concern. During the healing phase, local
infection or sepsis are the primary complications. Respiratory problems, primarily airway
compromise, are the primary complications during the acute stage of burn injury.
PTS: 1 DIF: Cognitive Level: Apply REF: 1040
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
37. After the acute stage and during the healing process, the primary complication from
burn injury is:
a. asphyxia.
b. shock.
c. renal shutdown.
d. infection.
ANS: D
During the healing phase, local infection and sepsis are the primary complications. Renal
shutdown is not a complication of the burn injury, but may be a result of the profound
shock.
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PTS: 1 DIF: Cognitive Level: Apply REF: 1040
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
38. An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her
father smothers the flames with a rug and calls an ambulance. She has sustained major
burns over much of her body. Which is important in her immediate care?
a. Wrap her in a blanket until help arrives.
b. Encourage her to drink clear liquids.
c. Place her in a tub of cool water.
d. Remove her burned clothing and jewelry.
ANS: D
In major burns, burned clothing should be removed to avoid further damage from
smoldering fabric and hot beads of melted synthetic materials. Jewelry is also removed to
eliminate the transfer of heat from the metal and constriction resulting from edema
formation. The burns should be covered, not wrapped with a clean cloth. A blanket can be
used initially to stop the burning process. Fluids should not be given by mouth to avoid
aspiration and water intoxication. The child should be kept warm. Placing her in a tub of
cool water will exacerbate heat loss.
PTS: 1 DIF: Cognitive Level: Apply REF: 1041
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
39. A young child has sustained a minor burn to the foot. Which is recommended for
treatment of a minor burn?
a. Apply ice to foot.
b. Apply cortisone ointment.
c. Apply an occlusive dressing.
d. Cleanse the wound with a mild soap and tepid water.
ANS: D
In minor burns, the best method of treatment is to cleanse the wound with a mild soap
and tepid water. Ice is not recommended. Most practitioners favor covering the wound
with an antimicrobial ointment (not cortisone) to reduce the risk of infection and to
provide some form of pain relief. The dressing is not occlusive but consists of
nonadherent fine-mesh gauze placed over the ointment and a light wrap of gauze dressing
that avoids interference with movement. This helps keep the wound clean and protects it
from trauma.
PTS: 1 DIF: Cognitive Level: Apply REF: 1041
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40. A toddler sustains a minor burn on the hand from hot coffee. Which is the first action
the nurse should recommend in treating this burn?
a. Apply ice to burned area.
b. Hold burned area under cool running water.
c. Break any blisters with a sterile needle.
d. Cleanse wound with soap and warm water.
ANS: B
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In minor burns, the best method to stop the burning process is to hold the burned area
under cool running water. Ice is not recommended. Removal of blisters is not generally
accepted therapy unless the injury is from a chemical substance. Cooling is necessary to
stop the burning process.
PTS: 1 DIF: Cognitive Level: Apply REF: 1041
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
41. A parent of a child with major burns asks the nurse why a high-calorie and highprotein diet is prescribed. Which response should the nurse make?
a. The diet promotes growth.
b. The diet will improve appetite.
c. The diet will diminish risks of stress-induced hyperglycemia.
d. The diet will avoid protein breakdown.
ANS: D
The diet must provide sufficient calories to meet the increased metabolic needs and
enough protein to avoid protein breakdown. Healing, not growth is the primary
consideration. Many children have poor appetites, and supplementation will be necessary.
Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the
liver glycogen stores are rapidly depleted.
PTS: 1 DIF: Cognitive Level: Apply REF: 1042
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
42. Fentanyl and midazolam (Versed) are given before dbridement of a childs burn
wounds. Which is the rationale for administration of these medications?
a. Promote healing.
b. Prevent infection.
c. Provide pain relief.
d. Limit amount of dbridement 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 dbridement.
PTS: 1 DIF: Cognitive Level: Understand REF: 1042
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
43. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 1042
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
44. Hydrotherapy is required to treat a child with extensive partial-thickness burn
wounds. Which is the primary purpose of hydrotherapy?
a. Dbride the wounds.
b. Increase peripheral blood flow.
c. Provide pain relief.
d. Destroy bacteria on the skin.
ANS: A
The water acts to loosen and remove sloughing tissue, exudate, and topical medications.
Increasing peripheral blood flow, providing pain relief, and destroying bacteria on the
skin may be secondary benefits to hydrotherapy, but the primary purpose is for
dbridement.
PTS: 1 DIF: Cognitive Level: Apply REF: 1043
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
45. A child with extensive burns requires dbridement. The nurse should anticipate which
priority goal related to this procedure?
a. Reduce pain.
b. Prevent bleeding.
c. Maintain airway.
d. Restore fluid balance.
ANS: A
Partial-thickness burns require dbridement of devitalized tissue to promote healing. The
procedure is painful and requires analgesia and sedation before the procedure. Preventing
bleeding, maintaining the airway, and restoring fluid balance are not goals associated with
dbridement.
PTS: 1 DIF: Cognitive Level: Apply REF: 1043
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
46. Biologic dressings are applied to a child with partial-thickness burns of both legs.
Which nursing intervention should be implemented?
a. Observing wounds for bleeding
b. Observing wounds for signs of infection
c. Monitoring closely for signs of shock
d. Splinting legs to prevent movement
ANS: B
When applied early to a superficial partial-thickness injury, biologic dressings stimulate
epithelial growth and hasten wound healing. If the dressing covers areas of heavy
microbial contamination, infection occurs beneath the dressing. In the case of partialthickness burns, such infection may convert the wound to a full-thickness injury.
Infection is the primary concern when biologic dressings are used.
PTS: 1 DIF: Cognitive Level: Apply REF: 1043
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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47. Which is one of the first signs of overwhelming sepsis in a child with burn injuries?
a. Seizures
b. Bradycardia
c. Disorientation
d. Decreased blood pressure
ANS: C
Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may
indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are
not initial manifestations of overwhelming sepsis.
PTS: 1 DIF: Cognitive Level: Understand REF: 1046
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
48. Which is an effective strategy to reduce the stress of burn dressing procedures?
a. Give child as many choices as possible.
b. Reassure child that dressing changes are not painful.
c. Explain to child why analgesics cannot be used.
d. Encourage child to master stress with controlled 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1046-1047
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
49. Which is an important consideration for the nurse when changing dressings and
applying topical medication to a childs abdomen and leg burns?
a. Apply topical medication with clean hands.
b. 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.
ANS: B
Frequent hand and forearm washing is the single most important element of the infectioncontrol 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 1045
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
50. The family of a 4-month-old infant will be vacationing at the beach. Which should the
nurse teach the family about exposure of the infant to the sun?
a. Use sun block on the infants nose and ear tips.
b. Use topical sunscreen product with a sun protective factor of 15.
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c. The infant can be exposed to the sun for 15-minute increments.
d. Keep the infant in total shade at all times.
ANS: D
The infant should be kept out of the sun or be physically shaded from it. Fabric with a
tight weave, such as cotton, offers good protection. Infants should be covered with
clothing or in the shade to prevent sun damage on the delicate skin at all times. The
blocker can protect the nose and ear tips, but none of the infants skin should be exposed.
Sunscreens should not be used extensively on infants younger than 6 months.
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TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
51. 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.
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TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
52. The nurse is teaching parents of toddlers about animal safety. Which should be
included in the teaching session?
a. Petting dogs in the neighborhood should be encouraged to prevent fear of dogs.
b. The toddler is safe to approach an animal if the animal is chained.
c. It is permissible for your toddler to feed treats to a dog.
d. 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).
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TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
53. 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?
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a. c.
CHAPTER 24 Nursing Care of the Child With an Alteration in Cellular Regulation/
Hematologic or Neoplastic Disorder
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.
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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.
The nurse should explain:
a. venipuncture discomfort is very brief.
b. only one venipuncture will be needed.
c. 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.
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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 childrens outdoor play area
b. Participation in dance activities in the playroom
c. Puppet play in the childs 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 childs energy level and minimize
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excess demands. The childs 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 childs room would not be overly tiring. Hide and seek,
dancing, and walking to the lobby would not conserve the anemic childs energy.
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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 toddlers diet. Which
explains why iron deficiency anemia is common during toddlerhood?
a. Milk is a poor source of iron.
b. Iron cannot be stored during fetal development.
c. Fetal iron stores are depleted by age 1 month.
d. Dietary iron cannot be started until age 12 months.
ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cows 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, iron-fortified formula, and cereals during the first 12 months of life.
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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?
a. It is caused by depression of the hematopoietic system.
b. It is easily diagnosed because of an infants emaciated appearance.
c. Clinical manifestations are similar regardless of the cause of the anemia.
d. Clinical manifestations result from a decreased intake of milk and the premature
addition of solid foods.
ANS: C
In iron deficiency anemia, the childs 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 iron-fortified solid foods and an excessive intake of milk.
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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?
a. They should be given with meals.
b. They should be stopped immediately if nausea and vomiting occur.
c. Adequate dosage will turn the stools a tarry green color.
d. Allow preparation to mix with saliva and bathe the teeth before swallowing.
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ANS: C
The nurse should prepare the mother for the anticipated change in the childs 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.
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TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
7. Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing
considerations include to:
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.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
8. The nurse is recommending how to prevent iron deficiency anemia in a healthy, term,
breast-fed 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 breast-fed 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.
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TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
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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.
Iron deficiency anemia affects the size and depth of the color.
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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.
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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.
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TOP: Integrated Process: Teaching/Learning
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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.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. Meperidine (Demerol) is not recommended for children in sickle cell crisis because it:
a. may induce seizures.
b. is easily addictive.
c. is not adequate for pain relief.
d. is 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
normeperidine-induced seizures. Meperidine is no more addictive than other narcotic
agents. Meperidine is adequate for pain relief. It is available for IV infusion.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
14. A school-age child is admitted in vasoocclusive sickle cell crisis. The childs care
should include:
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 is 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.
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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 patients 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.
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TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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.
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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. The purpose of this
therapy is to:
a. treat the disease.
b. eliminate excess iron.
c. decrease risk of hypoxia.
d. manage nausea and vomiting.
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
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effect of the disease management. Decreasing the risk of hypoxia and managing nausea
and vomiting are not the purposes of chelation therapy.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
18. In which of the conditions are all the formed elements of the blood simultaneously
depressed?
a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia
ANS: A
Aplastic anemia refers to a bone marrowfailure 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.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
19. A possible cause of acquired aplastic anemia in children is:
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.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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 bloodclotting 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 moon-shaped
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
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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.
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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?
a. Bone marrow failure in which all elements are suppressed
b. Deficiency in the production rate of globin chains
c. Diffuse fibrin deposition in the microvasculature
d. An excessive destruction of platelets
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 marrowfailure
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.
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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. 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.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. 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
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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.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. Myelosuppression, associated with chemotherapeutic agents or some malignancies
such as leukemia, can cause bleeding tendencies because of a(n):
a. decrease in leukocytes.
b. increase in lymphocytes.
c. vitamin C deficiency.
d. decrease in blood platelets.
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.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. A child with leukemia is receiving triple intrathecal chemotherapy consisting of
methotrexate, cytarabine, and hydrocortisone. The purpose of this is to prevent:
a. infection.
b. brain tumor.
c. drug side effects.
d. central nervous system (CNS) disease.
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.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
26. 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?
a. Syngeneic
b. Allogeneic
c. Monoclonal
d. Autologous
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 individuals own
marrow.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 890
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
28. 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.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
29. 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.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
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30. 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.
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MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
31. 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. Remaining 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 891
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
32. 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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 892
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33. The nurse is preparing a child for possible alopecia from chemotherapy. Which
should be included?
a. Explain to child that hair usually regrows in 1 year.
b. Advise child to expose head to sunlight to minimize alopecia.
c. Explain to child that wearing a hat or scarf is preferable to wearing a wig.
d. Explain to child that when hair regrows, it may have a slightly different color or
texture.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 892
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 893
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
35. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 895
TOP: Integrated Process: Nursing Process: Assessment
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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
36. A young child with human immunodeficiency virus (HIV) is receiving several
antiretroviral drugs. The purpose of these drugs is to:
a. cure the disease.
b. delay disease progression.
c. prevent spread of disease.
d. treat Pneumocystis carinii pneumonia.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 895
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
37. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 896
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapy
38. 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 childs
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 896
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
39. 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 childs right to privacy.
PTS: 1 DIF: Cognitive Level: Apply REF: 897
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 897
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
41. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 897-898
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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42. 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. These manifestations are most suggestive of:
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 898
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
43. An adolescent will receive a bone marrow transplant (BMT). The nurse should
explain that the bone marrow will be administered by which route?
a. Bone grafting
b. Bone marrow injection
c. IV infusion
d. Intra-abdominal infusion
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 recipients marrow when
given intravenously, this is the method of administration.
PTS: 1 DIF: Cognitive Level: Apply REF: 883
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
44. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 888
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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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.)
a. Finger sticks for blood work instead of venipunctures
b. Avoidance of IM injections
c. Acetaminophen (Tylenol) for mild pain control
d. Soft tooth brush for dental hygiene
e. Administration of packed red blood cells
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 aspirincontaining 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 885
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 childs 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
sport such as soccer and basketball are not recommended.
PTS: 1 DIF: Cognitive Level: Apply REF: 885
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.)
a. Limit fluids at bedtime.
b. Notify the health care provider if a fever of 38.5 C (101.3 F) or greater occurs.
c. Give penicillin as prescribed.
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d. Use ice packs to decrease the discomfort of vasoocclusive pain in the legs.
e. Notify the health care provider if your child begins to develop symptoms of a cold.
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 adhesionstasisthrombosisischemia 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 878
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. 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).
PTS: 1 DIF: Cognitive Level: Apply REF: 892
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
SHORT ANSWER
1. A toddler with leukemia is on intravenous chemotherapy treatments. The toddlers lab
results are WBC: 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. What is
this childs absolute neutrophil count (ANC)? (Record your answer in a whole number.)
ANS:
140
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 890
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
ESSAY
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 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 childs condition has been
medically evaluated.
CHAPTER 25 Nursing Care of the Child With an Alteration in Immunity or
Immunologic Disorder
MULTIPLE CHOICE
1. When teaching the mother of a young child about iron deficiency anemia, the nurse
would tell her that a rich source of iron is:
a
.
Egg whites
b
.
Cream of wheat
c
.
Bananas
d
.
Carrots
ANS: B
Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables,
cream of wheat, dried fruits, beans, nuts, and whole-grain breads.
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DIF: Cognitive Level: Application REF: Text Reference: 612
OBJ: Objective: 7 TOP: Topic: Iron Deficiency Anemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
2. The statement by a mother that may indicate a cause for her 9-month-old having iron
deficiency anemia is:
a
.
Formula is so expensive. We switched to regular milk
right away.
b
.
She almost never drinks water.
c
.
She doesnt really like peaches or pears, so we stick to
bananas for fruit.
d
.
I give her a piece of bread now and then. She likes to
chew on it.
ANS: A
Because cows milk contains very little iron, infants should drink iron-fortified formula
for the first year of life.
DIF: Cognitive Level: Analysis REF: Text Reference: 612
OBJ: Objective: 6 TOP: Topic: Iron Deficiency Anemia
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
3. The nurse would instruct the parent to give ferrous sulfate drops to the child:
a
.
With milk
b
.
With orange juice
c
.
With water
d
.
On a full stomach
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ANS: B
Vitamin C aids in the absorption of iron, whereas food and milk interfere with the
absorption of iron.
DIF: Cognitive Level: Application REF: Text Reference: 613
OBJ: Objective: 6 TOP: Topic: Iron Deficiency Anemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
4. The nurse would ask the patient with hemophilia A to reconsider a vacation he has
planned to:
a
.
The Caribbean for a cruise
b
.
Denver for skiing
c
.
Canada for a rail tour
d
.
New England for a bus tour
ANS: B
Hemophiliacs are discouraged from exercising in high altitudes and exposure to cold as
this depletes their already low oxygen concentration.
DIF: Cognitive Level: Analysis REF: Text Reference: 616
OBJ: Objective: 14 TOP: Topic: Hemophilia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
5. A 2-year-old child has been diagnosed with hemophilia A. The information the nurse
would include in a teaching plan about home care would be:
a
.
If bleeding occurs, apply pressure, ice, elevate, and rest
the extremity.
b
.
Childrens aspirin in lowered doses may be given for joint
discomfort.
c
.
A firm, dry toothbrush should be used to clean teeth at
least twice a day.
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d
.
Do not permit interactive play with other children.
ANS: A
When bleeding occurs, the traditional approach is to follow RICErest, ice, compression,
and elevation.
DIF: Cognitive Level: Application REF: Text Reference: 618
OBJ: Objective: 15 TOP: Topic: Hemophilia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. The nurse would teach the parents of a child with a low platelet count to avoid:
a
.
Ibuprofen
b
.
Aspirin
c
.
Caffeine
d
.
Prednisone
ANS: B
Aspirin interferes with platelet function and should be avoided to prevent the risk of
prolonged bleeding.
DIF: Cognitive Level: Application REF: Text Reference: 619
OBJ: Objective: 17 TOP: Topic: Leukemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. A child who is receiving a transfusion should be closely assessed for:
a
.
Fever
b
.
Lethargy
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c
.
Jaundice
d
.
Bradycardia
ANS: A
The child receiving a blood transfusion is observed for signs of a transfusion reaction
including chills, itching, fever, rash, headache, and back pain.
DIF: Cognitive Level: Analysis REF: Text Reference: 622
OBJ: Objective: 13 TOP: Topic: Blood Transfusion
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
8. On admission, a child with leukemia has widespread purpura and a platelet count of
19,000/mm3. The priority nursing intervention is:
a
.
Assessing neurological status
b
.
Inserting an intravenous line
c
.
Monitoring vital signs during platelet transfusions
d
.
Providing family education about how to prevent
bleeding
ANS: A
When platelets are low, the greatest danger is spontaneous intracranial bleeding.
Neurological assessments are therefore a priority of care.
DIF: Cognitive Level: Analysis REF: Text Reference: 619
OBJ: Objective: 17 TOP: Topic: Leukemia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
9. An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her
diaphragm have been found to be involved, including cervical and inguinal nodes. The
disease is in:
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a
.
Stage I
b
.
Stage II
c
.
Stage III
d
.
Stage IV
ANS: C
Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of
stage III Hodgkins disease.
DIF: Cognitive Level: Analysis REF: Text Reference: 623, Table 26-2
OBJ: Objective: N/A TOP: Topic: Hodgkins Disease
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell
crisis for severe abdominal pain. The nurse recognizes that the type of crisis the child is
most likely experiencing is:
a
.
Aplastic
b
.
Hyperhemolytic
c
.
Vaso-occlusive
d
.
Splenic sequestration
ANS: C
Vaso-occlusive crises or painful crises are caused by obstruction of blood flow by sickle
cells, infarctions, and some degrees of vasospasm.
DIF: Cognitive Level: Analysis REF: Text Reference: 615, Table 26-1
OBJ: Objective: 12 TOP: Topic: Sickle Cell Anemia
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KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. The statement made by a parent indicating understanding of health maintenance of a
child with sickle cell anemia is:
a
.
I should give my child a daily iron supplement.
b
.
It is important for my child to drink plenty of fluids.
c
.
He needs to wear protective equipment if he plays
contact sports.
d
.
He shouldnt receive any immunizations until he is older.
ANS: B
Prevention of dehydration, which can trigger the sickling process, is a priority goal in the
care of a child with sickle cell disease.
DIF: Cognitive Level: Analysis REF: Text Reference: 616
OBJ: Objective: 10 TOP: Topic: Sickle Cell Anemia
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. A newly married couple is seeking genetic counseling because they are both carriers
of the sickle cell trait. How can the nurse best explain their childrens risk of inheriting
this disease?
a
.
Every fourth child will have the disease; two others will
be carriers.
b
.
All of their children will be carriers, just as they are.
c
.
Each child has a one-in-four chance of having the disease
and a two-in-four chance of being a carrier.
d
.
The risk levels of their children cannot be determined by
this information.
ANS: C
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The sickle cell gene is inherited from both parents; therefore each offspring has a one-infour chance of inheriting the disease.
DIF: Cognitive Level: Analysis REF: Text Reference: 614, Figure 26-4
OBJ: Objective: 11 TOP: Topic: Sickle Cell Anemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13. A child with thalassemia major receives blood transfusions frequently. The nurse is
aware that a complication of repeated blood transfusions is:
a
.
Hemarthrosis
b
.
Hematuria
c
.
Hemoptysis
d
.
Hemosiderosis
ANS: D
As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are
stored in tissues.
DIF: Cognitive Level: Analysis REF: Text Reference: 617
OBJ: Objective: 13 TOP: Topic: Thalassemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. A child has just been diagnosed with acute lymphoblastic leukemia. The nurse is
aware that the result of an overproduction of immature white blood cells in the bone
marrow is:
a
.
Decreased T-cell production
b
.
Decreased hemoglobin
c
.
Increased blood clotting
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d
.
Increased susceptibility to infection
ANS: D
An overproduction of immature white blood cells increases the childs susceptibility to
infection.
DIF: Cognitive Level: Comprehension REF: Text Reference: 620
OBJ: Objective: 17 TOP: Topic: Leukemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. When the child receiving a transfusion complains of back pain and itching, the nurses
initial action would be to:
a
.
Notify the charge nurse
b
.
Disconnect IV lines immediately
c
.
Give Benadryl
d
.
Clamp off blood and keep line open with NS
ANS: D
If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep
the line open with normal saline, and notify the charge nurse.
DIF: Cognitive Level: Application REF: Text Reference: 622
OBJ: Objective: 18 TOP: Topic: Blood Transfusion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The nurse would include in a teaching plan about mouth care of a child receiving
chemotherapy to:
a
.
Use commercial mouthwash
b
.
Clean teeth with a soft toothbrush
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c
.
Avoid use of a Waterpik
d
.
Inspect the mouth weekly for ulcerations
ANS: B
A soft toothbrush reduces capillary damage and mucous membrane breakdown, and
prevents bleeding and infection. Commercial mouthwashes may kill oral flora that
combat infection. Waterpiks are useful for toughening gums.
DIF: Cognitive Level: Application REF: Text Reference: 622
OBJ: Objective: 17 TOP: Topic: Leukemia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. A 6-year-old with leukemia asks, Who will take care of me in heaven? The best
response for the nurse to make is:
a
.
Who do you think will take care of you?
b
.
Your grandparents and God will take care of you.
c
.
Your mom will know more about that than I do.
d
.
Why are you asking me that?
ANS: A
This response gives the child an opportunity to verbalize his or her feelings and concerns,
whereas the closed response in option 2 shuts off communication. The asking of a why
question is not therapeutic as it calls for justification.
DIF: Cognitive Level: Application REF: Text Reference: 627
OBJ: Objective: 17 TOP: Topic: Leukemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
18. When dealing with a preschool-age child with a life-threatening illness, the nurse
should remember that at this age the childs concept of death includes:
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a
.
That it is final
b
.
Only a fear of separation from her parents
c
.
That a person becomes alive again soon after death
d
.
An understanding based on simple logic
ANS: C
The preschooler views death as reversible and temporary.
DIF: Cognitive Level: Comprehension REF: Text Reference: 627, Table 26-3
OBJ: Objective: 19 TOP: Topic: Nursing Care of the Dying Child
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
19. The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and
petechiae on his extremities. The lab value that would be consistent with these symptoms
is:
a
.
Platelet count of 25,000/mm3
b
.
Hemoglobin level of 8 g/dl
c
.
Hematocrit level of 36%
d
.
Leukocyte count of 14,000/mm3
ANS: A
The normal platelet count is 150,000 to 400,000/mm3. This finding is very low,
indicating an increased bleeding potential.
DIF: Cognitive Level: Analysis REF: Text Reference: 619
OBJ: Objective: 3 TOP: Topic: Idiopathic Thrombocytopenic Purpura
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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20. The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is
firm and slightly distended. Also, there is no record of a bowel movement for the last 2
days. These assessment findings suggest the possibility of:
a
.
Peripheral neuropathy
b
.
Stomatitis
c
.
Myelosuppression
d
.
Hemorrhage
ANS: A
Peripheral neuropathy may be signaled by severe constipation resulting from decreased
nerve sensations in the bowel.
DIF: Cognitive Level: Analysis REF: Text Reference: 621
OBJ: Objective: 17 TOP: Topic: Leukemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
21. The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I
am so scared. The most appropriate nursing response to this comment is:
a
.
I understand how you must feel.
b
.
You shouldnt feel that way.
c
.
Is this the strongest feeling youve had today?
d
.
Tell me whats got you scared.
ANS: D
The nurse should encourage the adolescent to express her feelings and concerns.
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DIF: Cognitive Level: Analysis REF: Text Reference: 628
OBJ: Objective: 20
TOP: Topic: Adolescent With Cancer-Fear of Death
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
22. The most recent blood count for a child who received chemotherapy last week shows
neutropenia. The priority nursing diagnosis for this child is:
a
.
Risk for infection
b
.
Risk for hemorrhage
c
.
Altered skin integrity
d
.
Disturbance in body image
ANS: A
The child with neutropenia is at risk for infection.
DIF: Cognitive Level: Analysis REF: Text Reference: 620
OBJ: Objective: 17 TOP: Topic: Chemotherapy
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
23. The nurse takes into consideration an important focus of nursing care for the dying
child and his/her family, which is:
a
.
Nursing care should be organized to minimize contact
with the child.
b
.
Adequate oral intake is crucial to the dying child.
c
.
Families should be made aware that hearing is the last
sense to stop functioning before death.
d
.
It is best for the family if the nursing staff provides all of
the childs care.
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ANS: C
Hearing is intact even when there is a loss of consciousness.
DIF: Cognitive Level: Analysis REF: Text Reference: 631
OBJ: Objective: 22 TOP: Topic: Dying Child
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. The nursing care of a 12-year-old child receiving radiation therapy for Hodgkins
disease, should include:
Select all that apply.
a
.
Application of sunblock to the skin to prevent burning
b
.
Appetite stimulation
c
.
Conservation of energy
d
.
Provision for expressions of anger
e
.
Preparation for delay in sexual development
ANS: A, B, C, D, E
Sun block should be applied to skin after radiation to prevent burning. Low energy levels
produce anorexia and anger in many young patients. Radiation delays the development of
secondary sex characteristics and menses.
DIF: Cognitive Level: Analysis REF: Text Reference: 623
OBJ: Objective: 16 TOP: Topic: Effects of Radiation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse reviews the classic symptoms of thalassemia major (Cooleys anemia), such
as:
Select all that apply.
a
.
Hepatomegaly
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b
.
Jaundice
c
.
Protruding teeth
d
.
Pathological fractures
e
.
Cardiac failure
ANS: A, B, C, D, E
All of the options are classic signs of thalassemia major.
DIF: Cognitive Level: Comprehension REF: Text Reference: 618
OBJ: Objective: 8 TOP: Topic: Signs of Thalassemia Major
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Heath Promotion and Maintenance: Prevention and Early Detection of
Disease
3. The nurse reviews for a family how the development of synthetic recombinant
antihemophilic factor has improved the management of hemophilia, because this drug:
Select all that apply.
a
.
Eliminates the need for frequent transfusions
b
.
Can be administered by family at home
c
.
Prevents hemorrhage
d
.
Reduces cost of care of the hemophiliac
e
.
Reduces risk of HIV and hepatitis A and B transmission
ANS: A, B, D, E
The drug can be given at home by the family. Because it supplies the missing factor,
transfusions are not necessary and consequently the exposure to HIV and hepatitis A and
B is reduced. Cost of care is greatly reduced because hospitalizations and transfusions are
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not as frequently required. The drug does not prevent hemorrhage; it makes hemorrhage
manageable.
DIF: Cognitive Level: Analysis REF: Text Reference: 618
OBJ: Objective: 15 TOP: Topic: Hemophilia A
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
4. The family of a child receiving chemotherapy for leukemia should be taught to focus
on the childs care in regard to the need to:
Select all that apply.
a
.
Use a support group
b
.
Stimulate appetite
c
.
Maintain adequate hydration
d
.
Delay immunizations
e
.
Report exposure to infectious diseases
ANS: A, B, C, D, E
The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is
essential for the adequate therapeutic effect of the drugs. Because the drugs suppress the
bone marrow, children are at risk for infection, and the suppression will not allow the
antibody response needed for immunization. Support groups are helpful for emotional
support and realistic tips on care.
DIF: Cognitive Level: Analysis REF: Text Reference: 620
OBJ: Objective: 17 TOP: Topic: Chemotherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
COMPLETION
1. The nurse shows slides of red blood cells from a child with sickle cell anemia, noting
that in addition to their sickle shape, the cells contain the abnormal element of ________
______.
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ANS: hemoglobin S
CHAPTER 26 Nursing Care of the Child With an Alteration in Metabolism/Endocrine
Disorder
MULTIPLE CHOICE
1. Which postoperative order does the nurse clarify with the surgeon before discharging
the client who just had arthroscopic surgery on the right knee?
a.
Keep the right leg elevated on a soft pillow for 12 hours.
b.
Maintain nonweight bearing by right leg for 48 hours.
c.
Use ice on the knee for 24 hours.
d.
Administer two tablets of oxycodone/APAP (Tylox)
every 4 hours for pain.
ANS: D
Each tablet of Tylox has 5 mg oxycodone with 500 mg acetaminophen. If the client took
two tablets every 4 hours, the client would ingest a total of 6000 mg of acetaminophen,
well over the safe maximum dose of 4000 mg in 24 hours. The rest of the orders are
appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral
TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Planning)
2. An occupational therapist is treating a client with rheumatoid arthritis. Which
assessment finding in the client does the nurse share with the occupational therapist?
a.
Difficulty sleeping because of pain in the knees and
elbows
b.
Difficulty tying shoelaces and doing zippers on clothing
c.
Swollen knees with crepitus and limited range of motion
d.
Generalized joint stiffness that is worse in the early
morning
ANS: B
The functional assessment helps nurses and therapists measure how functional the client
is with activities of daily living, including dressing. The occupational therapist can assist
the client to explore clothing options that are easier to manage with arthritic fingers. The
other findings would not necessarily need to be shared with the occupational therapist for
the treatment plan.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
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TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareCollaboration with Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is caring for a client who is to have a computed tomography (CT) scan of the
leg. Which assessment question does the nurse ask the client before the procedure?
a.
Do you have any metal clips, plates, or pins in your
body?
b.
Have you had anything to eat or drink in the last 6 hours?
c.
Do you have someone to drive you home after the
procedure?
d.
Do you have any allergies to shrimp, scallops, or other
seafood?
ANS: D
IV contrast that contains iodine may be required for CT scans to rule out malignancy. The
client should be assessed for allergy to shellfish, which contain high amounts of iodine.
The other questions are not relevant when a CT scan is to be obtained.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlError Prevention) MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is assessing a client who reports severe knee pain after a fall. Which
question does the nurse ask to determine the radiation of the pain?
a.
What makes the pain better or worse?
b.
Are you able to bear any weight on the knee at all?
c.
Does the pain move to another area from your knee?
d.
How would you rate the pain on a scale of 1 to 10?
ANS: C
To determine radiation of the pain, the nurse asks the client if the pain moves to another
area from the knee. The other questions address the amount, functional impact, and
alleviating or aggravating factors of the pain.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 1111
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management) MSC: Integrated Process: Nursing Process (Assessment)
5. Which instruction does the nurse give to the client before he or she has
electromyography (EMG)?
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a.
Make sure that you have someone to drive you home
after the test.
b.
Do not eat or drink anything for at least 6 hours before
the test.
c.
You will have to avoid heavy lifting for 24 hours
following the test.
d.
Do not take your cyclobenzaprine (Flexeril) on the 2 days
before the test.
ANS: D
Electromyography (EMG) testing measures nerve signal transmission to and through
muscles. Skeletal muscle relaxants such as Flexeril can affect test results and should be
avoided for at least 2 days before the test. The other instructions are not relevant before
EMG testing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Teaching/Learning
6. The nurse is caring for a client with prostate cancer. Which laboratory finding indicates
to the nurse that the cancer has metastasized to the bone?
a.
Serum calcium, 21.6 mg/dL
b.
Creatine kinase, 55 U/mL
c.
Alkaline phosphatase, 45 IU/mL
d.
Lactate dehydrogenase, 120 U/L
ANS: A
Metastasis of tumor to bone results in release of calcium into the bloodstream, causing an
elevation of the serum calcium level (normal range, 9 to 10.5 mg/dL). The other
laboratory values are within normal limits and do not indicate metastasis to the bone.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk
PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment)
7. The nurse is caring for a client who presents with achy jaw pain. Which assessment
technique does the nurse use to determine whether the client has inflammation of the
temporomandibular joint (TMJ)?
a.
Checking for decayed, fractured, loose, or missing teeth
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b.
Observing the jaw joint as the client chews a piece of
food
c.
Palpating the joint during movement for tenderness or
crepitus
d.
Observing for asymmetric joint protrusion when the
clients mouth is closed
ANS: C
The temporomandibular joints are best assessed by palpation while the client opens his or
her mouth. The other assessment techniques are not effective for assessing possible TMJ
inflammation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process
(Assessment)
8. The nurse is caring for a client who is able to flex the right arm forward without
difficulty or pain but is unable to abduct the arm because of pain and muscle spasms.
Which condition does the nurse suspect based on these assessment findings?
a.
Dislocated elbow
b.
Lesion in the rotator cuff
c.
Osteoarthritis of the shoulder
d.
Atrophy of the supraspinatus muscle
ANS: B
Rotator cuff lesions may cause limited range of motion and pain and muscle spasm
during abduction, whereas forward flexion stays fairly normal. The assessment findings
are not consistent with the other conditions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process
(Assessment)
9. The nurse is assessing a client who is suspected of having muscular dystrophy. Which
statement by the client indicates that more teaching may be needed about the creatine
kinase (CK) test that the health care provider has ordered?
a.
The Lasix that I took this morning may affect the test
results.
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b.
The CK test is 90% accurate in demonstrating muscle
trauma or injury.
c.
The level of CK will be decreased with skeletal muscle
disease.
d.
When muscle is damaged, CK isoenzymes are released
over time.
ANS: C
All of the statements are correct, except that the level of creatine kinase will increase with
any skeletal muscle damage.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 1114
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk
PotentialDiagnostic Tests) MSC: Integrated Process: Teaching/Learning
10. A client has cancer and a pacemaker, and suffers from claustrophobia. Which
diagnostic test is the best indicator of the clients bone metastasis?
a.
Magnetic resonance imaging (MRI)
b.
Arthrogram
c.
Ultrasound
d.
Thallium bone scan
ANS: D
Because the client has a pacemaker and claustrophobia, MRI would not be an option as a
diagnostic test. The arthrogram is an x-ray used to visualize bone chips and torn
ligaments within a joint. Ultrasound is used to assess soft tissue disorders, traumatic joint
injuries, and osteomyelitis. The thallium bone scan is ideal for obtaining information
about the extent of bone cancer such as osteosarcoma or bony metastases.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk
PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)
11. Which client does the nurse assess first at the start of the nursing shift?
a.
Client wanting to know information about a magnetic
resonance imaging (MRI) test scheduled in 3 hours
b.
Client who is verbalizing mild discomfort after an
electromyography (EMG)
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c.
Client who reports increased pain and swelling after an
arthroscopy
d.
Client who refuses to drink more fluids after a nuclear
medicine scan
ANS: C
The client who should be the first priority is the one who is reporting increased pain and
swelling after arthroscopy; this could indicate complications from the surgery. The client
with mild discomfort after an EMG should be assessed for pain, but mild discomfort is
common for this procedure. Pain medication can then be administered. After a nuclear
medicine scan, the client must increase fluids to flush out the radioisotope used in the
scan. The nurse could then visit with the client who had questions about the upcoming
MRI.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care (Establishing Priorities)
MSC: Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. The nurse is performing a medical history and physical assessment on an older client.
Which common findings in the older client are related to the musculoskeletal system?
(Select all that apply.)
a.
Decrease in bone density
b.
Decrease in falls due to lack of activity
c.
Atrophy of the muscle tissue
d.
Decrease in bone prominence
e.
Degeneration of cartilage
f.
Reduced range of motion of the joints
ANS: A, C, E, F
In the older adult, common findings include a decrease in bone density, atrophy of muscle
tissue, cartilage degeneration, and a decrease in range of motion. In addition, falls
increase as the result of kyphotic posture, widened gait, and an alteration in the center of
gravity, creating an unsteady walking pattern. Increased bony prominences are observed
in the older adult because less soft tissue is present to cushion the bone, and pressure
ulcers are a threat.
CHAPTER 27 Nursing Care of the Child With an Alteration in Genetics
MULTIPLE CHOICE
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1. A parent whose child has been diagnosed with a cognitive deficit should be counseled
that intellectual impairment:
a.
is usually due to a genetic defect.
b.
may be caused by a variety of factors.
c.
is rarely due to first-trimester events.
d.
is usually caused by parental intellectual impairment.
ANS: B
There is a multitude of causes for intellectual impairment. In nearly half of the cases, a
specific cause has not been identified. Only 5% of children with intellectual impairment
are affected by a genetic defect. One-third of children with intellectual impairment are
affected by first-trimester events. Intellectual impairment can be transmitted to a child
only if the parent has a genetic disorder.
DIF: Cognitive Level: Comprehension REF: p. 799
OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance
2. A parent asks the nurse why a developmental assessment is being conducted for a child
during a routine well-child visit. The nurse answers based on the knowledge that routine
developmental assessments during well-child visits are:
a.
not necessary unless the parents request them.
b.
the best method for early detection of cognitive disorders.
c.
frightening to parents and children and should be avoided.
d.
valuable in measuring intelligence in children.
ANS: B
Early detection of cognitive disorders can be facilitated through assessment of
development at each well-child examination. Developmental assessment is a component
of all well-child examinations. Developmental assessments are not frightening when the
parent and child are educated about the purpose of the assessment and are not intended to
measure intelligence.
DIF: Cognitive Level: Application REF: p. 799|p. 801
OBJ: Nursing Process Step: Implementation
MSC: Health Promotion and Maintenance
3. The father of a child recently diagnosed with developmental delay is very rude and
hostile toward the nurses. This father was cooperative during the childs evaluation a
month ago. What is the best explanation for this change in parental behavior?
a.
The father is exhibiting symptoms of a psychiatric illness.
b.
The father may be abusing the child.
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c.
The father is resentful of the time he is missing from work for this
appointment.
d.
The father is in the anger stage of the grief process.
ANS: D
After a child is diagnosed with a developmental delay, the family may feel grief. The
grief process begins with a stage of disbelief and denial and then progresses to anger. It is
not possible to determine that a parent is exhibiting symptoms of a psychiatric illness on
the basis of a single situation. The scenario does not give any information to suggest child
abuse. Although the father may have difficulty balancing his work schedule with medical
appointments for his child, a more likely explanation for his behavior change is that he is
grieving the loss of a normal child.
DIF: Cognitive Level: Comprehension REF: pp. 802-803
OBJ: Nursing Process Step: Evaluation MSC: Psychosocial Integrity
4. An appropriate nursing diagnosis for a child with a cognitive dysfunction who has a
limited ability to anticipate danger is:
a.
Impaired social interaction.
b.
Deficient knowledge.
c.
Risk for injury.
d.
Ineffective coping.
ANS: C
The nurse needs to know that limited cognitive abilities to anticipate danger lead to risk
for injury. Impaired social interaction is indeed a concern for the child with a cognitive
disorder but does not address the limited ability to anticipate danger. Because of the
childs cognitive deficit, knowledge will not be retained and will not decrease the risk for
injury. Ineffective individual coping does not address the limited ability to anticipate
danger.
DIF: Cognitive Level: Application REF: p. 801
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Health Promotion and Maintenance
5. Anticipatory guidance for the family of a preadolescent with a cognitive dysfunction
should include information about:
a.
institutional placement.
b.
sexual development.
c.
sterilization.
d.
clothing.
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ANS: B
Preadolescents who have a cognitive dysfunction may have normal sexual development
without the emotional and cognitive abilities to deal with it. It is important to assist the
family and child through this developmental stage. Preadolescence does require the child
to be institutionalized. Sterilization is not an appropriate intervention when a child has a
cognitive dysfunction. By the time a child reaches preadolescence, the family should
have received counseling on age-appropriate clothing.
DIF: Cognitive Level: Application REF: p. 802
OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance
6. The mother of a 9-year-old child with Down syndrome discusses the childs language
abilities. The nurse is not surprised to learn which information about the childs language
development?
a.
Can take turns during conversation
b.
Has good grammar
c.
Can speak a foreign language
d.
Has difficulty in carrying on a conversation
ANS: A
Social language involves maintaining a conversation on a specific topic and taking turns
during the conversation. Children with Down syndrome generally have good social
language. The language development of children with Down syndrome involves
difficulty with grammar but strength in social usage. It would not be expected for
children with Down syndrome to be characterized as typically knowing a foreign
language. Children with Down syndrome have a general strength in social language such
as greeting others and carrying on a conversation in a give-and-take manner and have
social skills that exceed expected skills on the basis of intellectual capacity.
DIF: Cognitive Level: Comprehension REF: pp. 805-806
OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance
7. The infant with Down syndrome is closely monitored during the first year of life for
which condition?
a.
Thyroid complications
b.
Orthopedic malformations
c.
Dental malformation
d.
Cardiac abnormalities
ANS: D
The high incidence of cardiac defects in children with Down syndrome makes assessment
for signs and symptoms of these defects important during the first year. Infants with
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Down syndrome are not known to have thyroid complications. Orthopedic malformations
may be present, but special attention is given to assessment for cardiac and
gastrointestinal abnormalities. Dental malformations are not a major concern compared
with the life-threatening complications of cardiac defects.
DIF: Cognitive Level: Comprehension REF: p. 805
OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance
8. Which action is contraindicated when a child with Down syndrome is hospitalized?
a.
Determine the childs vocabulary for specific body functions.
b.
Assess the childs hearing and visual capabilities.
c.
Encourage parents to leave the child alone.
d.
Have meals served at the childs usual meal times.
ANS: C
The child with Down syndrome needs routine schedules and consistency. Having familiar
people present, especially parents, helps to decrease the childs anxiety. To communicate
effectively with the child, it is important to know the childs particular vocabulary for
specific body functions. Children with Down syndrome have a high incidence of hearing
loss and vision problems and should have hearing and vision assessed whenever they are
in a healthcare facility. Routine schedules and consistency are important to children.
DIF: Cognitive Level: Application REF: p. 807
OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity
9. A nurse is giving a parent information about autism. Which statement made by the
parent indicates understanding of the teaching?
a.
Autism is characterized by periods of remission and exacerbation.
b.
The onset of autism usually occurs before 2 1/2 years of age.
c.
Children with autism have imitation and gesturing skills.
d.
Autism can be treated effectively with medication.
ANS: B
The onset of autism usually occurs before 30 months of age. Autism does not have
periods of remissions and exacerbations. Autistic children lack imitative skills.
Medications are of limited use in children with autism.
DIF: Cognitive Level: Application REF: p. 812
OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance
10. Which should the nurse keep in mind when planning to communicate with a child
who is autistic?
a.
The child has normal verbal communication.
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b.
Expect the child to use sign language.
c.
The child may exhibit monotone speech and echolalia.
d.
The child is not listening if she is not looking at the nurse.
ANS: C
Children with autism have abnormalities in the production of speech such as a monotone
voice or echolalia and inappropriate volume, pitch, rate, rhythm, or intonation. The child
has impaired verbal communication and abnormalities in the production of speech. Some
autistic children may use sign language, but it is not assumed. Children with autism often
are reluctant to initiate direct eye contact.
DIF: Cognitive Level: Comprehension REF: p. 812
OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity
11. What is the best intervention when a child with autism is hospitalized?
a.
Limit the individuals who enter the childs room.
b.
Perform all of the childs activities of daily living for her.
c.
Make sure the nurses know this child may be violent.
d.
Assign the strongest nurse to control the child.
ANS: A
The child with autism is often unable to tolerate the slightest change in routine. Limiting
who enters the childs room to those knowledgeable about the childs routine will facilitate
the childs adaptation to the hospital environment. The most important nursing
consideration when planning care for a child with autism is to assign the child to a nurse
who is familiar with the childs routine and to follow that routine. The child should be
encouraged to perform toileting and self-care activities as she normally would if she were
not in the hospital. There is no indication that the child will be violent. Limiting the
number of individuals in contact with the child and maintaining a routine will decrease
any chance of violence. Strength should not be a consideration in assignments.
DIF: Cognitive Level: Application REF: p. 814
OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity
12. Intense stress and isolation as a result of caring for a child with developmental
disabilities often lead parents to:
a.
heightened parental achievement.
b.
overuse of the healthcare system.
c.
overindulgence and obesity.
d.
child abuse.
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ANS: D
Child abuse and developmental disabilities are often associated. Stress and isolation may
hinder parents from reaching their potential. Parents may feel isolated from support and
healthcare services. They report that professionals have limited understanding of their
childrens needs. Although overindulgence and obesity may occur, the best answer is child
abuse.
DIF: Cognitive Level: Comprehension REF: p. 799
OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity
13. A child with Asperger syndrome has also been diagnosed with depression. The nurse
understands that two or more disorders in an individual is termed:
a.
comorbidity.
b.
congenital syndrome.
c.
mental retardation.
d.
developmental impairment.
ANS: A
Comorbidity by definition means more than one disorder in an individual. Congenital
syndrome means the disorder originated before birth. Mental retardation refers to
subaverage intellectual functioning. Developmental impairment refers to functional level.
DIF: Cognitive Level: Comprehension REF: p. 799
OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity
14. Self-injury, fecal smearing, and severe temper tantrums in a preschool child are
symptoms of:
a.
mild intellectual impairment.
b.
severe intellectual impairment.
c.
psychosocial deprivation.
d.
separation anxiety.
ANS: B
Self-injury, fecal smearing, and severe temper tantrums in a preschool child are
symptoms of severe intellectual impairment. Mild intellectual impairment is
characterized by social isolation or depression. Psychosocial deprivation may be a cause
of intellectual impairment. The symptoms listed are characteristic of severe intellectual
impairment. Symptoms of separation anxiety include protest, despair, and detachment.
DIF: Cognitive Level: Analysis REF: p. 800
OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity
15. Throughout their life span, cognitively impaired children are less capable of
managing environmental challenges and are at risk for which problem?
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a.
Nutritional deficits
b.
Visual impairments
c.
Physical injuries
d.
Psychiatric problems
ANS: C
Safety is a challenge for cognitively impaired children. Decreased capability to manage
environmental challenges may lead to physical injuries. Nutritional deficits are related
more to dietary habits and the caregivers understanding of nutrition. Visual impairments
are unrelated to cognitive impairment. Psychiatric problems may coexist with cognitive
impairment but are not environmental challenges.
DIF: Cognitive Level: Comprehension REF: p. 804
OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance
16. The parents of a child born at 36 weeks of gestation who had respiratory problems
requiring 3 days of oxygen therapy are concerned that the infant may have an intellectual
impairment. The best nursing statement to the parents is which of the following?
a.
A diagnosis of intellectual impairment is not made until the child
enters school and experiences academic failure.
b.
Routine assessment of development during pediatric visits is the best
method of early detection.
c.
The baby is not at risk for an intellectual impairment.
d.
Tests for intellectual impairments are not reliable for children younger
than 3 years.
ANS: B
Routine assessment of development from birth is the best method for early detection of
problems. Intellectual impairment may be detected before school age. The baby may be at
risk for an intellectual impairment as a result of poor oxygenation. The Denver
Developmental Screening test may be unreliable for children younger than 3 years, but
other assessment tools are available. Several neuropsychological tests are available.
DIF: Cognitive Level: Application REF: p. 799
OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance
17. Parents of a child with fragile X syndrome ask the nurse about genetic transmission of
this syndrome. In response, the nurse correctly explains that fragile X syndrome is:
a.
most commonly seen in girls.
b.
acquired after birth.
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c.
usually transmitted by the male carrier.
d.
usually transmitted by the female carrier.
ANS: D
The gene causing fragile X syndrome is transmitted by the mother. Fragile X syndrome is
most common in males, is congenital, and is not transmitted by a male carrier.
DIF: Cognitive Level: Application REF: p. 807
OBJ: Nursing Process Step: Implementation
MSC: Health Promotion and Maintenance
18. The best setting for daytime care for a 5-year-old autistic child whose mother works
is:
a.
private day care.
b.
public school.
c.
his own home with a sitter.
d.
a specialized program that facilitates interaction by use of behavioral
methods.
ANS: D
Autistic children can benefit from specialized educational programs that address their
special needs. Day care programs generally do not have resources to meet the needs of
severely impaired children. To best meet the needs of an autistic child, the public school
may refer the child to a specialized program. A sitter might not have the skills to interact
with an autistic child.
DIF: Cognitive Level: Application REF: p. 813
OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance
19. Parents have learned that their 6-year-old child is autistic. The nurse may help the
parents to cope by explaining that the child will:
a.
have abnormal ways of interacting with other children and adults.
b.
outgrow the condition by early adulthood.
c.
have average social skills.
d.
probably have age-appropriate language skills.
ANS: A
Abnormal interaction with people is one of the several characteristics of autism. No
evidence supports the belief that autism is outgrown. Autistic children have abnormal
ways of relating to people (social skills). Speech and language skills are usually delayed
in autistic children.
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DIF: Cognitive Level: Application REF: p. 812
OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity
20. An autistic child is hospitalized with asthma. The nurse should plan care so that the:
a.
parents expectations are met.
b.
childs routine habits and preferences are maintained.
c.
child is supported through the autistic crisis.
d.
parents need not be at the hospital.
ANS: B
Children with autism are often unable to tolerate even slight changes in routine. Focus of
care is on the childs needs rather than on the parents desires. Autism is a life-long
condition. The presence of the parents is almost always required when an autistic child is
hospitalized.
DIF: Cognitive Level: Application REF: p. 814
OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity
MULTIPLE RESPONSE
1. Which of the following treatment guidelines would be contraindicated when
counseling the family of an infant with fragile X syndrome? Select all that apply.
a.
Advise genetic testing for family members.
b.
Delay speech therapy until the child is 2 years of age.
c.
Educate the family that their child will probably have normal
intelligence.
d.
Refer the family to an early intervention program.
ANS: B, C
Speech therapy should be started in the first year of life and continued on an ongoing
basis. Waiting until the child is 2 years old would not be appropriate. Children with
fragile X syndrome have a high incidence of intellectual, language, and social
dysfunctions. It is the most common inherited cause of mental retardation. Because
fragile X syndrome is an X-linked recessive disorder, genetic testing is appropriate. Early
intervention programs assess the child and develop a plan of intervention; this is
appropriate.
DIF: Cognitive Level: Application REF: p. 808
OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance
2. A nurse is assessing a newborn for facial feature characteristics associated with fetal
alcohol syndrome. Which characteristics should the nurse expect to assess? Select all that
apply.
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a.
Short palpebral fissures
b.
Smooth philtrum
c.
Low set ears
d.
Inner epicanthal folds
e.
Thin upper lip
ANS: A, B, E
Infants with fetal alcohol syndrome may have characteristic facial features, including
short palpebral fissures, a smooth philtrum (the vertical groove in the median portion of
the upper lip), and a thin upper lip. Low set ears and inner epicanthal folds are associated
with Down syndrome.
DIF: Cognitive Level: Analysis REF: p. 809
OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity
3. A nurse should plan to implement which interventions for a child admitted with
inorganic failure to thrive? Select all that apply.
a.
Observation of parentchild interactions
b.
Assignment of different nurses to care for the child from day to day
c.
Use of 28 calorie per ounce concentrated formulas
d.
Administration of daily multivitamin supplements
e.
Role-modeling appropriate adultchild interactions
ANS: A, D, E
The nurse should plan to assess parentchild interactions when a child is admitted for
nonorganic failure to thrive. The observations should include how the child is held and
fed, how eye contact is initiated and maintained, and the facial expressions of both the
child and the caregiver during interactions. Role modeling and teaching appropriate
adultchild interactions (including holding, touching, and feeding the child) will facilitate
appropriate parentchild relationships, enhance parents confidence in caring for their child,
and facilitate expression by the parents of realistic expectations based on the childs
developmental needs. Daily multivitamin supplements with minerals are often prescribed
to ensure that specific nutritional deficiencies do not occur in the course of rapid growth.
The nursing staff assigned to care for the child should be consistent. Providing a
consistent caregiver from the nursing staff increases trust and provides the child with an
adult who anticipates his or her needs and who is able to role model child care to the
parent. Caloric enrichment of food is essential, and formula may be concentrated in
titrated amounts up to 24 calories per ounce. Greater concentrations can lead to diarrhea
and dehydration.
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CHAPTER 28 Nursing Care of the Child With an Alteration in Behavior, Cognition, or
Development
MULTIPLE CHOICE
1. When a parent asks the nurse to describe what is meant by a learning disability, the
nurses most helpful response would be:
a
.
A child may have difficulty with perception, language,
comprehension, or memory.
b
.
It is characterized by inattention, impulsiveness, and
hyperactivity.
c
.
The childs intellectual ability limits his learning.
d
.
The child has difficulty learning because of brain
damage.
ANS: A
Learning disability is an educational term. Children with learning disabilities may have
average to above-average intelligence, but they may experience difficulties in perception,
language, comprehension, and conceptualization.
DIF: Cognitive Level: Application REF: 739 OBJ: 2
TOP: Learning Disability KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
2. What would be the appropriate response to an adolescent who states, This has been the
worst day of my life?
a
.
You should focus your mind on positive thoughts.
b
.
Everybody has a bad day now and then.
c
.
Youre young. What could be so terrible?
d
.
Tell me about the worst day in your life.
ANS: D
The nurse establishes a rapport with the adolescent by acknowledging his or her feelings
and giving the adolescent full attention.
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DIF: Cognitive Level: Application REF: 735, NCP 32-1
OBJ: 3 TOP: Suicide KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im
not going to talk about that! Its none of your business, anyway! Leave me alone! The
nurse recognizes that the outburst was stimulated by the fact that the adolescent is:
a
.
Acting out and needs to be brought under control so the
conference can continue
b
.
Trying to shift the focus of the conference away from
himself, and the nurse needs to refocus
c
.
Demonstrating that this problem requires the assistance
of a psychiatrist
d
.
Responding to the discrediting of his parents, which
causes anxiety in the child; thus reassurance is needed
that blame will not be directed at anyone
ANS: D
Discrediting parents threatens the childs security and creates anxiety.
DIF: Cognitive Level: Comprehension REF: 730 OBJ: 4
TOP: Suicide KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. The nurse answering phone calls at a local suicide prevention hotline would recognize
the statement indicating the greatest risk of suicide is:
a
.
I just needed to talk to someone to keep myself from
thinking silly thoughts about killing myself.
b
.
My parents arent home and wont be back for 4 hours.
That should be enough time for the pills to work. Ive got
a hundred of them.
c
.
My dad will be home first, so hell find me. So I think Ill
use his gun. I hope he didnt lock the cabinet.
d
.
My girlfriend is here with me. She told me to call
because I was talking crazy about killing myself.
ANS: B
The risk of death increases when there is a definite plan of action, the means are readily
available, and the person has few resources for help and support.
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DIF: Cognitive Level: Analysis REF: 764 OBJ: 3
TOP: Suicide KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
5. The nurse assesses an early sign of depression in a 15- year-old boy who previously
was active in a band, and had saved his money to buy a special guitar when he:
a
.
Gives up the band to spend time with his girlfriend
b
.
Spends all of his time at the library studying in order to
qualify for the honor society
c
.
Gives his guitar away and spends his time listening to
music in his room
d
.
Withdraws all of his money out of the bank to buy an
expensive leather jacket
ANS: C
A major depression is characterized by a prolonged behavioral change from baseline that
interferes with school, family life, and age-specific activities, frequently signaled by
giving prized possessions away.
DIF: Cognitive Level: Analysis REF: 733 OBJ: 3
TOP: Depression KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
6. A mother is concerned because her teenage son is always in trouble for fighting at
school and always seems to be angry. She mentions that her husband drinks a bit. The
understanding guiding the nurses response is:
a
.
The boy is displaying antisocial behavior and should be
evaluated for mental illness.
b
.
He is displaying one of the typical defense patterns of
children of alcoholics and should receive immediate
treatment.
c
.
The mother is displaying her own anger with her
husbands drinking, and she needs immediate
intervention.
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d
.
This boy is only one member of the family affected by
alcoholism, and all members should receive immediate
intervention.
ANS: D
Early recognition of and intervention for children of alcoholics are paramount. This
adolescent is using the coping pattern of acting-out behaviors to deal with the family
situation.
DIF: Cognitive Level: Comprehension REF: 738 OBJ: 9
TOP: Substance Abuse KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
7. The school nurse suggests to the classroom teacher that the most appropriate classroom
intervention for a child with attention deficit hyperactivity disorder would be:
a
.
Seat the child in the back of the room to prevent
distractions for other children.
b
.
Pair the child with a student buddy to offer reminders to
pay attention.
c
.
Divide work assignments into shorter periods with breaks
in between.
d
.
Separate the child from others to increase his focus on
schoolwork.
ANS: C
The child with attention deficit hyperactivity disorder needs breaks between periods of
work and study.
DIF: Cognitive Level: Application REF: 739, Box 32-2
OBJ: 11 TOP: Attention Deficit Hyperactivity Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
8. The nurse explains that the person who is bulimic:
a
.
Is severely underweight
b
.
Alternates binge eating with purging
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c
.
Is an introverted perfectionist
d
.
Has extremely close family relationships
ANS: B
Bulimia is characterized by alternating binge eating and purge behavior.
DIF: Cognitive Level: Knowledge REF: 740 OBJ: 12
TOP: Bulimia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
9. A 14-year-old girl with obsessive-compulsive disorder tells the nurse other teens tease
her because she washes her hands many times during the school day. The nurse is aware
that this disorder puts the adolescent at greater risk for:
a
.
Anorexia nervosa
b
.
Suicidal behavior
c
.
Attention deficit hyperactivity disorder
d
.
Learning disability
ANS: B
OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high
risk for adolescents with OCD.
DIF: Cognitive Level: Comprehension REF: 732 OBJ: N/A
TOP: Obsessive-Compulsive Disorder KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
10. The statement made by a parent of an adolescent with anorexia nervosa indicating an
understanding of this condition is:
a
.
There really isnt anything to worry about. Dont they say
you can never be too thin?
b
.
My daughter just doesnt have much of an appetite.
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c
.
She is just trying to punish me for divorcing her father.
d
.
She seems to see herself as fat, even though her weight is
below normal.
ANS: D
Individuals with anorexia nervosa have a disturbed body image, which this parent
correctly recognizes.
DIF: Cognitive Level: Application REF: 740, Figure 32-2
OBJ: 12 TOP: Anorexia Nervosa
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
11. An appropriate nursing intervention for a hospitalized child who is autistic would be
to:
a
.
Place the child in a location where she can watch all of
the activity on the unit.
b
.
Use the childs chronological age as a guide for
communication.
c
.
Keep the childs room free of toys or objects that she
might want to take home with her.
d
.
Organize care to provide as few disruptions to the routine
as possible.
ANS: D
During hospitalization, the nurse should provide a highly structured environment with
few distractions for a child who is autistic.
DIF: Cognitive Level: Application REF: 732 OBJ: N/A
TOP: Autism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
12. A nurse planning to speak with a parent support group about childhood autism would
include the information:
a
.
Significant signs of the disorder manifest by 1 year of
age.
b
.
The earliest signs of autism are impulsivity and
overactivity.
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c
.
Autism is usually diagnosed when the child goes to
elementary school.
d
.
Medications can cure childhood autism.
ANS: A
Failure to use eye contact and look at others, poor attention span, and poor orienting to
ones name are significant signs of dysfunction by 1 year of age.
DIF: Cognitive Level: Application REF: 732 OBJ: N/A
TOP: Autism KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
13. An adolescent is brought to the emergency department after an automobile accident.
When the nurse approaches the adolescent, he becomes combative. The nurse notes his
speech is slurred and his gait is ataxic. The nurse suspects the adolescent has used:
a
.
Alcohol
b
.
Cocaine
c
.
Amphetamines
d
.
PCP
ANS: A
Behavioral signs of alcohol ingestion include slurred speech, short attention span,
drowsiness, combativeness, and violence.
DIF: Cognitive Level: Analysis REF: 736, Table 32-1
OBJ: 7 TOP: Substance Abuse
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
14. When the nurse is collecting a nursing history, an adolescent states that she has tried
speed. The nurse recognizes this as the street name for:
a
.
Barbiturates
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b
.
Cocaine
c
.
Methamphetamine
d
.
Marijuana
ANS: C
Speed is the street name for methamphetamine.
DIF: Cognitive Level: Knowledge REF: 737, Table 32-2
OBJ: 7 TOP: Substance Abuse
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15. The nurse explains that the member of the child guidance team who is a medical
doctor with special training in psychoanalytic theory is the:
a
.
Psychiatrist
b
.
Psychoanalyst
c
.
Psychologist
d
.
Counselor
ANS: A
The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a
psychologist. The psychologist is not a medical doctor, and neither is the counselor.
DIF: Cognitive Level: Application REF: 731 OBJ: 5
TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
16. Because young children cannot express themselves well, the nurse uses the
therapeutic intervention that allows children to act out their feelings, which is:
a
.
Art therapy
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b
.
Play therapy
c
.
Music therapy
d
.
Bibliotherapy
ANS: B
Play therapy allows a young child to act out with dolls or figures concerns that the child
may be unable to adequately express verbally.
DIF: Cognitive Level: Comprehension REF: 731 OBJ: 1
TOP: Play Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic
child, but has the negative aspect of:
a
.
Sedating the child
b
.
Impairing cognition
c
.
Causing hypotension
d
.
Creating fluid retention
ANS: B
Stimulants that decrease the hyperactivity in the autistic child also impair cognition and
may increase the potential of self-injuring behavior.
DIF: Cognitive Level: Application REF: 732 OBJ: 2
TOP: Autism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18. A 9-year-old has been admitted to the hospital after huffing lighter fluid. The nurse
should assess for:
a
.
Depressed respirations
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b
.
Severe vomiting
c
.
Frightening hallucinations
d
.
Elevation of temperature
ANS: A
Inhaling hydrocarbons depresses the central nervous system, including respiratory rate
and general sensorium.
DIF: Cognitive Level: Application REF: 735 OBJ: 7
TOP: Substance Abuse KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physical Integrity: Reducing Risk
19. As the pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate,
the nurse assesses possible dyslexia when the child:
a
.
Becomes hyperactive and ceases to read
b
.
Reads the word GOD as DOG
c
.
Makes up a story rather than reading the text
d
.
Stutters as he reads
ANS: B
Dyslexics often transpose a word as they read; for example, the word is GOD, but it
appears to the dyslexic child as the word DOG.
DIF: Cognitive Level: Application REF: 739 OBJ: N/A
TOP: Dyslexia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
MULTIPLE RESPONSE
1. The nurse describes the members of a mental health team for child guidance as
including a:
Select all that apply.
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a
.
Psychiatrist
b
.
Pediatrician
c
.
Psychologist
d
.
Dietitian
e
.
Social worker
ANS: A, B, C, E
The traditional members of the child guidance team are the psychiatrist, pediatrician,
psychologist, and social worker. The dietitian is not usually on the treatment team.
DIF: Cognitive Level: Comprehension REF: 731 OBJ: 5
TOP: Members of the Child Guidance Team
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
2. The school nurse cautions a group of parents about the prevalence of children who get
high by inhaling hydrocarbons and fluorocarbons, such as:
Select all that apply.
a
.
Glue
b
.
Chlorine
c
.
Cleaning fluid
d
.
Copy machine toner
e
.
Aerosol sprays
ANS: A, C, E
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Although there are many products that could be inhaled, the most frequently used
products are glue, cleaning fluid, aerosol sprays, Freon, shoe polish, and gasoline
products.
DIF: Cognitive Level: Application REF: 736, Table 32-1
OBJ: 7 TOP: Inhaling Hydrocarbons
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
3. The nurse takes into consideration in planning the care of an adolescent with anorexia
nervosa that the cause of this disorder is:
Select all that apply.
a
.
Discomfort relative to emerging sexuality
b
.
Fear of intimacy
c
.
Pervasive low self-esteem
d
.
Egocentricity
e
.
Inability to meet developmental needs
ANS: A, B, C, D, E
All options listed are considered to be the cause of anorexia nervosa.
DIF: Cognitive Level: Application REF: 740 OBJ: 12
TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
COMPLETION
1. The nurse documents that every time the child is directed to discuss the relationship
with her brother, she complains of shortness of breath and begins to have asthma-like
symptoms. The nurse assesses this behavior as a ____________________ reaction.
ANS: psychosomatic
DIF: Cognitive Level: Analysis REF: 731 OBJ: 1
TOP: Psychosomatic Reaction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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NOT: Rationale: A psychosomatic reaction is one in which a dysfunction of the body has
an emotional or mental cause.
2. The nurse assists with the intervention of ____________________ therapy, which
provides a physical and social environment that is stable and therapeutic.
ANS: milieu
CHAPTER 29 Nursing Care During a Pediatric Emergency
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 613
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 parents left him, and he refused the staffs 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.
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Parents should be encouraged to be with their child. If parents restrict visits, they may
begin a pattern of misunderstanding the childs cues and not meeting his needs.
PTS: 1 DIF: Cognitive Level: Analyze REF: 613
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, the nurse should
recognize that the child may likely see hospitalization as:
a.
punishment.
b.
threat to childs self-image.
c.
an opportunity for regression.
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 615
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.
Infants
b.
Toddlers
c.
Preschoolers
d.
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 615
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 Im not ready. The nurse should recognize this as which
description?
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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 Im not ready can be characteristic behavior when an individual needs to
maintain some control over a situation.
PTS: 1 DIF: Cognitive Level: Analyze REF: 616
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
6. The most common initial reaction of parents to illness or injury and hospitalization in
their child is:
a.
anger.
b.
fear.
c.
depression.
d.
disbelief.
ANS: D
Disbelief is the most common initial response of parents. This is especially true if the
illness is sudden and serious. 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 617
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 isnt fair that you get everything and we
have to stay with the neighbors. Which is the nurses best assessment of this situation?
a
.
The siblings are immature and probably spoiled.
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b
.
Jealousy and resentment are common reactions to the
illness or hospitalization of a sibling.
c
.
Family has ineffective coping mechanisms to deal with
chronic illness.
d
.
The siblings need to better understand their sisters
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 617
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
8. An appropriate nursing intervention to minimize separation anxiety in a hospitalized
toddler would be to:
a.
provide for privacy.
b.
encourage parents to room in.
c.
explain procedures and routines.
d.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 628
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 cooperating.
d.
Tell him what a big boy he is to be so quiet.
ANS: A
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 621
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 injury from falling off her bicycle. Which will help her most in her adjustment to
the hospital?
a
.
Explain hospital schedules to her, such as mealtimes.
b
.
Use terms such as honey and dear to show a caring
attitude.
c
.
Explain when parents can visit and why siblings
cannot come to see her.
d
.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 614
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.
Apply a Band-Aid.
b.
Ask her why she wants a Band-Aid.
c.
Explain why a Band-Aid is not needed.
d.
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 623
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 nurses 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 621
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
wouldnt 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 parent that the illness is not serious.
c
.
Encourage parent to maintain a sense of control.
d
.
Assess further why parent has excessive guilt
feelings.
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ANS: A
Guilt is a common response of parents when a child is hospitalized. They may blame
themselves for the childs 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 parents 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 627
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
.
A 4-year-old boy with first day post-appendectomy
surgery
b
.
A 6-year-old boy with pneumonia
c
.
A 15-year-old boy admitted with a vasoocclusive
sickle cell crisis
d
.
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 15-year-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).
PTS: 1 DIF: Cognitive Level: Apply REF: 618 | 621
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.
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b
.
I think I would like for my siblings to visit me but not
my friends.
c
.
I hope my friends dont 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 615
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 sitting on the parents lap. Which technique should the nurse implement to
complete the physical exam?
a
.
Ask the parent to place the child in the hospital crib.
b
.
Take the child and parent to the exam room.
c
.
Perform the exam while the child is on the parents
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 parents lap. For young
children, particularly infants and toddlers, preserving parentchild contact is the best
means of decreasing the need for or stress of restraint. The entire physical examination
can be done in a parents 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 622
TOP:Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
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17. A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis,
reports difficulty 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 interactive
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 childs routine is
establishing a daily schedule. This approach is most suitable for noncritically ill schoolage and adolescent children who have mastered the concept of time. It involves
scheduling the childs 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 622
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
hospitalized. 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 because of
hospitalization.
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d
.
The child was too young to be potty-trained.
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. Successful potty-training can be started at 2 years of age if the child
is ready.
PTS: 1 DIF: Cognitive Level: Apply REF: 624
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 do a blood pressure on the
child. Which is the appropriate procedure for obtaining the blood pressure?
a
.
Take the blood pressure in the playroom.
b
.
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 obtained
because the child was in the playroom.
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 childs hospital bed. Documenting that the blood pressure was not
obtained because the child was in the playroom is inappropriate.
PTS: 1 DIF: Cognitive Level: Apply REF: 624
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 pneumonia 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 thermometer while
taking the childs blood pressure.
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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 childs
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 childs anxiety.
PTS: 1 DIF: Cognitive Level: Apply REF: 631
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
21. 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.
c.
b.
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 parents 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 613
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 childs condition
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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 childs
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 632
TOP:Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
2. A nurse plans therapeutic play time for a hospitalized child. Which are the benefits of
therapeutic play? (Select all that apply.)
a.
Serves as method to assist disturbed children
b.
Allows the child to express feelings
c.
The nurse can gain insight into the childs feelings.
d.
The child can deal with concerns and feelings.
e.
Gives the child a structured play environment
ANS: B, C, D
Therapeutic 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
childrens 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 625
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.)
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 630
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.)
a.
Equipment noise
b.
Privacy
c.
Caring behavior by the nurse
d.
Unfamiliar smells
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 633
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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 medical 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 stuffiness
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.
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