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Test Bank Hockenberry Wongs Essentials Pediatric Nursing
10th 2016
Child Growth and Development in Early Childhood (St. Petersburg College)
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
1
Table of Contents
Table of Contents
1
Chapter 01: Perspectives of Pediatric Nursing
2
Chapter 02: Family, Social, Cultural, and Religious Influences on Child Health Promotion
8
Chapter 03: Developmental and Genetic Influences on Child Health Promotion
22
Chapter 04: Communication and Physical Assessment of the Child
39
Chapter 05: Pain Assessment and Management in Children
68
Chapter 06: Childhood Communicable and Infectious Diseases
77
Chapter 07: Health Promotion of the Newborn and Family
92
Chapter 08: Health Problems of Newborns
115
Chapter 09: Health Promotion of the Infant and Family
137
Chapter 10: Health Problems of Infants
148
Chapter 11: Health Promotion of the Toddler and Family
157
Chapter 12: Health Promotion of the Preschooler and Family
168
Chapter 13: Health Problems of Toddlers and Preschoolers
175
Chapter 14: Health Promotion of the School-Age Child and Family
189
Chapter 15: Health Promotion of the Adolescent and Family
196
Chapter 16: Health Problems of School-Age Children and Adolescents
203
Chapter 17: Quality of Life for Children Living with Chronic or Complex Diseases
216
Chapter 18: Impact of Cognitive or Sensory Impairment on the Child and Family
228
Chapter 19: Family-Centered Care of the Child During Illness and Hospitalization
240
Chapter 20: Pediatric Variations of Nursing Interventions
253
Chapter 21: The Child with Respiratory Dysfunction
268
Chapter 22: The Child with Gastrointestinal Dysfunction
283
Chapter 23: The Child with Cardiovascular Dysfunction
300
Chapter 24: The Child with Hematologic or Immunologic Dysfunction
314
Chapter 25: The Child with Cancer
329
Chapter 26: The Child with Genitourinary Dysfunction
357
Chapter 27: The Child with Cerebral Dysfunction
369
Chapter 28: The Child with Endocrine Dysfunction
384
Chapter 29: The Child with Musculoskeletal or Articular Dysfunction
393
Chapter 30: The Child with Neuromuscular or Muscular Dysfunction
405
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
2
Chapter 01: Perspectives of 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
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.
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 African-American boys
ranging in ages 15 to 19 years?
a. Suicide
b. Cancer
c. Firearm homicide
d. Occupational injuries
ANS: C
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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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
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 secondleading 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
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
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
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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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
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
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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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
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 selfgoverning. 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
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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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
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
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
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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d. Buying toys for a hospitalized child
e. Learning about the familys religious preferences
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
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 11
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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Chapter 02: Family, Social, Cultural, and Religious Influences on Child
Health Promotion
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: 16
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which family theory explains how families react to stressful events and suggests factors that promote
adaptation to these events?
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: 16
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is the term for a family in which the paternal grandmother, the parents, and two minor children live
together?
a. Blended
b. Nuclear
c. Binuclear
d. Extended
ANS: D
An extended family contains at least one parent, one or more children, and one or more members (related or
unrelated) other than a parent or sibling. A blended family contains at least one 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.
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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PTS: 1 DIF: Cognitive Level: Remember REF: 16
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 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: 16
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: 21
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: 21
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.
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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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 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: 22
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: 22
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: 23
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:
a. permissive.
b. dictatorial.
c. democratic.
d. authoritarian.
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
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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: 25
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 agreed-on actions. Realistic
goals should be set for this age group. Parents should structure the environment to prevent unnecessary
difficulties. Requests for behavior change should be phrased in a positive manner to provide direction for the
child. Withdrawal of love and approval is never appropriate or effective. Discipline strategies should be
appropriate to the 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: 25
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 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: 27
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.
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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: 28
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: 29
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
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: 32
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
16. Which term best describes a group of people who share a set of values, beliefs, practices, social
relationships, law, politics, economics, and norms of behavior?
a. Race
b. Culture
c. Ethnicity
d. Social group
ANS: B
Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and
decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and
practices that serve as a frame of reference for individual perceptions and judgments. Race is defined as a
division of mankind possessing traits that are transmissible by descent and are sufficient to characterize it as a
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distinct human type. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and
linguistic heritage. A social group consists of systems of roles carried out in groups. Examples of primary
social groups include the family and peer groups.
PTS: 1 DIF: Cognitive Level: Remember REF: 36
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
17. Which term best describes the emotional attitude that ones own ethnic group is superior to others?
a. Culture
b. Ethnicity
c. Superiority
d. Ethnocentrism
ANS: D
Ethnocentrism is the belief that ones way of living and behaving is the best way. This includes the emotional
attitude that the values, beliefs, and perceptions of ones ethnic group are superior to those of others. Culture is
a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions
of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that
serves as a frame of reference for individual perception and judgments. Ethnicity is an affiliation of a set of
persons who share a unique cultural, social, and linguistic heritage. Superiority is the state or quality of being
superior; it does not include ethnicity.
PTS: 1 DIF: Cognitive Level: Understand REF: 39
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
18. Currently, the fastest-growing segment of the homeless population in the United States consists of:
a. families.
b. runaway adolescents.
c. migrant farm workers.
d. individuals with mental disorders.
ANS: A
Homeless individuals lack resources and community ties necessary to provide for their own adequate shelter.
One of the most pressing problems in the United States is the rapidly growing number of homeless families,
which currently account for 50% of the nations homeless. Runaway (or throwaway) adolescents are often
victims of physical and social abuse. Although it is a significant issue, this is not the fastest-growing segment
of the homeless population. Migrant farm workers form one of the most severely disadvantaged groups in the
United States. They have a mobile existence, which is detrimental for children. They do not constitute the
fastest-growing segment of the homeless population. Individuals with mental disorders may be homeless. They
do not constitute the fastest-growing segment of the homeless population.
PTS: 1 DIF: Cognitive Level: Understand REF: 43
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
19. Maria, a Spanish-speaking 5-year-old girl, has started kindergarten in an English-speaking school. Crying
most of the time, she appears helpless and unable to function in this new situation. Which description best
explains Marias behavior?
a. Lacks adequate culture for attending school
b. Lacks the maturity needed in school
c. Is experiencing culture shock
d. Is experiencing minority group discrimination
ANS: C
Culture shock is the helpless feeling and state of disorientation felt by an outsider attempting to adapt to a
different culture group. Her inability to speak English inhibits her ability to interact. This would explain Marias
inability to function in this new situation. There is no evidence to support that Maria lacks adequate culture or
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maturity needed in school, or that she is experiencing minority group discrimination.
PTS: 1 DIF: Cognitive Level: Analyze REF: 38
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
20. When minority groups immigrate to another country, a certain degree of cultural or ethnic blending occurs
through the involuntary process of:
a. acculturation.
b. ethnocentrism.
c. culture shock.
d. cultural sensitivity.
ANS: A
Acculturation is the gradual changes that are produced in a culture by the influence of another culture that
cause one or both cultures to become more similar. The minority culture is forced to learn the majority culture
to survive. Ethnocentrism is the belief that ones way of living and behaving is the best way. This includes the
emotional attitude that the values, beliefs, and perceptions of ones ethnic group are superior to those of others.
This would limit the blending. Culture shock is the helpless feeling and state of disorientation felt by an
outsider attempting to adapt to a different culture group. This would limit the blending. Cultural sensitivity is
an awareness of cultural similarities and differences. The nurse should develop the dynamics of cultural
sensitivity to provide culturally competent care.
PTS: 1 DIF: Cognitive Level: Understand REF: 38
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
21. Which is a frequent health problem of migrant children and adolescents in the United States?
a. Suicide
b. Diabetes
c. Tuberculosis
d. Cardiovascular disease
ANS: C
The rate of tuberculosis among migrant families is high. A high-risk factor for the children of migrant families
is the migration of the families from areas that have high prevalence of tuberculosis; significant health issues,
suicide, diabetes, and cardiovascular disease are not more prevalent in this population.
PTS: 1 DIF: Cognitive Level: Understand REF: 43
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
22. The nurse observes that the families who do not show up for scheduled clinic appointments are usually
from minority cultural groups. The best explanation for this is that these families often differ from the
dominant culture because they:
a. lack education.
b. avoid health care.
c. are more forgetful.
d. view time differently.
ANS: D
Each cultural group has different conceptions of time and waiting. The dominant culture in the United States
has a fairly rigid view of time. Other cultures may be late or miss activities because other issues take
precedence over the appointment. Education is not the issue. It is the concept of time in the cultural group. It is
not done to avoid health care. The family usually believes that the appointment can be made for a later time.
The family does not forget the time, but other issues take priority.
PTS: 1 DIF: Cognitive Level: Apply REF: 44
TOP: Integrated Process: Nursing Process: Planning
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MSC: Area of Client Needs: Psychosocial Integrity
23. The Vietnamese mother of a child being seen in the clinic avoids eye contact with the nurse. The best
explanation for this, considering cultural differences, is that the parent:
a. feels responsible for her childs illness.
b. feels inferior to the nurse.
c. is embarrassed to seek health care.
d. is showing respect for the nurse.
ANS: D
In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly
into the nurses eyes as a sign of respect. The nurse providing culturally competent care would recognize that
feeling responsible for the illness, feeling inferior, or embarrassment are not reasons for the mother to avoid
eye contact with the nurse.
PTS: 1 DIF: Cognitive Level: Understand REF: 46
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
24. The belief that health is a state of harmony with nature and the universe is common in which culture?
a. Japanese
b. African-American
c. Native American
d. Hispanic-American
ANS: C
Many cultures ascribe attributes of health to natural forces. Many individuals of the Native-American culture
view health as a state of harmony with nature and the universe. This belief is not consistent with the Japanese,
African-American, or Hispanic-American cultural groups.
PTS: 1 DIF: Cognitive Level: Remember REF: 51
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
25. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the
broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicle, and juices are left. Which
statement would best explain this?
a. Parent is trying to feed child only what child likes most.
b. Parent is trying to restore normal balance through appropriate hot remedies.
c. Hispanics believe the evil eye enters when a person gets cold.
d. Hispanics believe an innate energy, called chi, is strengthened by eating soup.
ANS: B
In several groups, including Filipino, Chinese, Arabic, and Hispanic cultures, hot and cold describe certain
properties completely unrelated to temperature. Respiratory conditions such as pneumonia are cold conditions
and are treated with hot foods. The parent may be trying to feed the child only what the child likes most, but it
is unlikely that a toddler would consistently prefer the broth to Jell-O, Popsicle, and juice. The evil eye applies
to a state of imbalance of health, not curative actions. Chinese individuals believe in chi as an innate energy.
PTS: 1 DIF: Cognitive Level: Apply REF: 51
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
26. A nurse is taking a history on a low-income Hispanic toddler. The parent tells the nurse that occasional
diarrhea is treated with azogue, a mercury compound commonly used in the parents native Mexico. What
should the nurse recognize about this remedy?
a. It is harmless.
b. It is dangerous.
c. It has a scientific basis.
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d. It has importance in certain religious practices.
ANS: B
The ingestion of mercury is extremely dangerous for children. Solutions containing mercury are not harmless.
The nurse should work with folk healers or respected members of the culture to teach the family of the dangers
of mercury ingestion. No scientific basis exists for the use of mercury to treat diarrhea.
PTS: 1 DIF: Cognitive Level: Understand REF: 48
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
27. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The childs mother
says she has rubbed the edge of a coin on her childs oiled skin. What explanation should the nurse recognize
about this?
a. Child abuse
b. Cultural practice to rid the body of disease
c. Cultural practice to treat enuresis or temper tantrums
d. Child discipline measure common in the Vietnamese culture
ANS: B
Rubbing the edge of a coin on a childs oiled skin is descriptive of coining. The welts are created by repeatedly
rubbing a coin on the childs oiled skin. The mother is attempting to rid the childs body of disease. The mother
was engaged in an attempt to heal the child. This is not child abuse or discipline.
PTS: 1 DIF: Cognitive Level: Understand REF: 48
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity: Cultural Diversity
28. The father of a hospitalized child tells the nurse, He cant have meat. We are Buddhist and vegetarians. The
nurses best intervention is to:
a. order the child a meatless tray.
b. ask a Buddhist priest to visit.
c. explain that hospital patients are exempt from dietary rules.
d. help the parent understand that meat provides protein needed for healing.
ANS: A
It is essential for the nurse to respect the religious practices of the child and family. The nurse should arrange a
dietary consult to ensure that nutritionally complete vegetarian meals are prepared by the hospital kitchen. It is
not necessary to ask a Buddhist priest to visit. The nurse should be able to arrange for a vegetarian tray. The
nurse should not encourage the child and parent to go against their religious beliefs. Nutritionally complete,
acceptable vegetarian meals should be provided.
PTS: 1 DIF: Cognitive Level: Apply REF: 53
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
29. In which cultural group is good health considered to be a balance between yin and yang?
a. Asians
b. Australian aborigines
c. Native Americans
d. African-Americans
ANS: A
In Chinese health beliefs, the forces termed yin and yang must be kept in balance to maintain health. The belief
in this balance is not consistent with Australian aborigines, Native Americans, or African-Americans.
PTS: 1 DIF: Cognitive Level: Remember REF: 50
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
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30. A young child from Mexico is hospitalized for a serious illness. The father tells the nurse that the child is
being punished by God for being bad. The nurse should recognize that this is a(n):
a. health belief common in this culture.
b. early indication of potential child abuse.
c. misunderstanding of the familys common beliefs.
d. belief common when fortune tellers have been used.
ANS: A
A common health belief in the Mexican-American cultural group is that health is controlled by the
environment, fate, and the will of God. The fathers comment has no relation to child abuse. The father would
not misunderstand the familys beliefs. It is a cultural belief that health is controlled by the environment, fate,
and the will of God. Mexicans may use the services of curandero (healers), not fortune tellers.
PTS: 1 DIF: Cognitive Level: Apply REF: 51
TOP: Integrated Process: Nursing Process: Evaluation
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: 20
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse is conducting a teaching session on the use of time-out as a discipline measure to parents of
toddlers. Which are correct strategies the nurse should include in the teaching session? (Select all that apply.)
a. Time-out as a discipline measure cannot be used when in a public place.
b. A rule for the length of time-out is 1 minute per year.
c. When the child misbehaves, one warning should be given.
d. The area for time-out can be in the family room where the child can see the television.
e. When the child is quiet for the specified time, he or she can leave the room.
ANS: B, C, E
A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an audible bell to record
the time rather than a watch. When the child misbehaves, one warning should be given. When the child is quiet
for the duration of the time, he or she can then leave the room. Time-out can be used in public places and the
parents should be consistent on the use of time-out. Implement time-out in a public place by selecting a
suitable area or explain to children that time-out will be spent immediately on returning home. The time-out
should not be spent in an area from which the child can view the television. Select an area for 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: 27
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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: 30
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Teaching and Learning
4. Children are taught the values of their culture through observation and feedback, relative to their own
behavior. In teaching a class on cultural competence, the nurse should be aware that which factor(s) may be
culturally determined? (Select all that apply.)
a. Degree of competition
b. Racial variation
c. Determination of status
d. Social roles
e. Geographic boundaries
ANS: A, C, D
Degree of competition, determination of status, and social roles are all factors that are determined by the
assumptions, beliefs, and practices of the members of the culture. In cultures that value individual
resourcefulness, competition would be acceptable. Status is culturally determined and varies according to each
culture. Some will ascribe higher status to age or socioeconomic status. Social roles also are influenced by the
culture. Race and culture are two distinct attributes. The racial grouping describes transmissible traits, whereas
the culture is determined by the pattern of assumptions, beliefs, and practices that unconsciously frames or
guides the outlook and decisions of a group of people. Cultural development may be limited by geographic
boundaries. It is not the boundaries that are culturally determined.
PTS: 1 DIF: Cognitive Level: Analyze REF: 36
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
5. Research is being done on the development of assets in children. A community that is supportive of children
has which external assets? (Select all that apply.)
a. Unstructured environments to allow for freedom of choice
b. Social competencies to make positive choices
c. Empowerment to feel safe and secure
d. Positive values to direct choice
e. Boundaries to set expectations and actions
ANS: C, E
Young people need to feel valued by their community and able to contribute to others. They need to feel safe
and secure. They also need boundaries to help set expectations and actions. To develop appropriately, children
need boundaries and expectations. With these, they will learn what is expected of them and what behaviors are
acceptable to the community. Social competencies to make positive choices and boundaries to set expectations
and actions are internal assets that, when developed, help the child make positive choices.
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PTS: 1 DIF: Cognitive Level: Analyze REF: 40
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
6. A nurse is planning care for a Spanish-speaking child and family. The nurse speaks limited Spanish. Which
interventions should the nurse plan when caring for this child and family? (Select all that apply.)
a. Ask a visitor to interpret.
b. Use a language-line telephone interpreter if a hospital interpreter is not available.
c. Use written cards with common phrases in the Spanish language.
d. Ask the family to provide an interpreter.
e. When using a hospital interpreter, speak to the family not the interpreter.
ANS: B, C, E
If a live interpreter is not available, the nurse should use a language line telephone interpreter. The nurse
should use cards with common greetings, phrases, and names of body parts in the familys language. When
using a hospital interpreter, the nurse should speak directly to the family and allow the interpreter to translate.
Visitors or other family members should not be used as interpreters because of the risk of misinterpretation of
medical terms.
PTS: 1 DIF: Cognitive Level: Apply REF: 45
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
7. A nurse is working in a clinic that serves a culturally diverse population of children. The nurse should plan
care, understanding that which complementary and alternative practices may be used by families of this diverse
population? (Select all that apply.)
a. Seeking another doctors opinion
b. Seeking advice from a curandero or curandera
c. Using acupuncture or acupressure as a therapy
d. Consulting an herbalist
e. Consulting a kahuna
ANS: B, C, D, E
The curandero (male) or curandera (female) of the Mexican-American community is believed to have healing
powers that are a gift from God. The Asian family may consult an herbalist, knowledgeable in medicines, or
perhaps a specialized practitioner of Asian therapies, including acupuncture (insertion of needles) or
acupressure (application of pressure). Native Hawaiians consult kahunas and practice hooponopono to heal
family imbalance or disputes. The nurse may encounter use of these practices. Consulting another doctor
would not be a complementary or alternative practice expected in a culturally diverse population.
PTS: 1 DIF: Cognitive Level: Apply REF: 48
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
8. A nurse is caring for an African-American child recently admitted to the hospital. The nurse should be
aware of which broad cultural characteristics for this child when planning care? (Select all that apply.)
a. Silence may indicate a lack of trust.
b. Maintaining constant eye contact may be viewed as aggressive.
c. Self-care and folk medicine do not play a role in healthcare.
d. Illness may be seen as the will of God.
e. No importance is attached to nonverbal behavior.
ANS: A, B, D
A nurse should be aware of the African-American broad cultural characteristics, which include: initial eye
contact to show respect; maintaining eye contact can be viewed as aggressive, silence may indicate a lack of
trust, and illness may be seen as the will of God. Self-care and folk medicine are prevalent in this culture, and
importance is placed on nonverbal behavior.
PTS: 1 DIF: Cognitive Level: Apply REF: 50
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TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
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: 33
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 33
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Poverty has serious implications for children and families. Social and cultural deprivation, including limited
employment opportunities, inferior educational opportunities, inferior or no access to health care, and a lack of
public services, is referred to as the _______________ type of poverty.
ANS:
invisible
Social and cultural deprivation, including limited employment opportunities, inferior educational opportunities,
inferior or no access to health care, and a lack of public services is the definition of invisible poverty. Visible
poverty is the lack of money or material resources, including insufficient clothing, poor sanitation, and
deteriorating housing.
PTS: 1 DIF: Cognitive Level: Remember REF: 42
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
2. A parent of a 12-year-old child states to the nurse, My 12-year-old watches TV constantly while at homeis
this OK? The nurse should recommend to the parent that television viewing should be limited to _____ hours a
day? (Record your answer in a whole number.)
ANS:
2
Children may identify closely with people or characters portrayed in reading materials, movies, and television
programs and commercials. Pediatric nurses can educate and support parents on the effects of mass media on
their children by recommending that television viewing should be limited to 2 hours a day or less.
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PTS: 1 DIF: Cognitive Level: Apply REF: 41
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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Chapter 03: Developmental and Genetic Influences on Child Health
Promotion
MULTIPLE CHOICE
1. An infant gains head control before sitting unassisted. The nurse recognizes that this is which type of
development?
a.
Cephalocaudal
b.
Proximodistal
c.
Mass to specific
d.
Sequential
ANS: A
The pattern of development that is head-to-tail, or cephalocaudal, direction is described by an infants ability to
gain head control before sitting unassisted. The head end of the organism develops first and is large and
complex, whereas the lower end is smaller and simpler, and development takes place at a later time.
Proximodistal, or near to far, is another pattern of development. Limb buds develop before fingers and toes.
Postnatally, the child has control of the shoulder before achieving mastery of the hands. Mass to specific is not
a specific pattern of development. In all dimensions of growth, a definite, sequential pattern is followed.
PTS: 1 DIF: Cognitive Level: Understand REF: 39
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
2. Which refers to those times in an individuals life when he or she is more susceptible to positive or negative
influences?
a.
Sensitive period
b.
Sequential period
c.
Terminal points
d.
Differentiation points
ANS: A
Sensitive periods are limited times during the process of growth when the organism will interact with a
particular environment in a specific manner. These times make the organism more susceptible to positive or
negative influences. The sequential period, terminal points, and differentiation points are developmental times
that do not make the organism more susceptible to environmental interaction.
PTS: 1 DIF: Cognitive Level: Remember REF: 40
TOP:Integrated Process: Nursing Process: Planning
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MSC:Area of Client Needs: Health Promotion and Maintenance
3. An infant who weighs 7 pounds at birth would be expected to weigh how many pounds at age 1 year?
a.
14
b.
16
c.
18
d.
21
ANS: D
In general, birth weight triples by the end of the first year of life. For an infant who was 7 pounds at birth, 21
pounds would be the anticipated weight at the first birthday; 14, 16, or 18 pounds is below what would be
expected for an infant with a birth weight of 7 pounds.
PTS: 1 DIF: Cognitive Level: Understand REF: 41
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
4. By what age does birth length usually double?
a.
1 year
b.
2 years
c.
4 years
d.
6 years
ANS: C
Linear growth or height occurs almost entirely as a result of skeletal growth and is considered a stable
measurement of general growth. On average, most children have doubled their birth length at age 4 years. One
and 2 years are too young for doubling of length. Most children will have achieved the doubling by age 4
years.
PTS: 1 DIF: Cognitive Level: Remember REF: 42
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
5. Parents of an 8-year-old child ask the nurse how many inches their child should grow each year. The nurse
bases the answer on the knowledge that after age 7 years, school-age children usually grow what number of
inches per year?
a.
1
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b.
2
c.
3
d.
4
24
ANS: B
The growth velocity after age 7 years is approximately 5 cm (2 inches) per year. One inch is too small an
amount. Three and 4 inches are greater than the average yearly growth after age 7 years.
PTS: 1 DIF: Cognitive Level: Apply REF: 42
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
6. Parents express concern that their pubertal daughter is taller than the boys in her class. The nurse should
respond with which statement regarding how the onset of pubertal growth spurt compares in girls and boys?
a. It occurs earlier in boys.
b. It occurs earlier in girls.
c. It is about the same in both boys and girls.
d. In both boys and girls, the pubertal growth spurt depends on growth in infancy.
ANS: B
Usually, the pubertal growth spurt begins earlier in girls. It typically occurs between the ages of 10 and 14
years for girls and 11 and 16 years for boys. The average earliest age at onset is 1 year earlier for girls. There
does not appear to be a relation to growth during infancy.
PTS: 1 DIF: Cognitive Level: Apply REF: 42
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
7. A 13-year-old girl asks the nurse how much taller she will get. She has been growing about 2 inches per year
but grew 4 inches this past year. Menarche recently occurred. The nurse should base her response on which
statement?
a. Growth cannot be predicted.
b. Pubertal growth spurt lasts about 1 year.
c. Mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.
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ANS: D
At the time of the beginning of menstruation or the skeletal age of 13 years, most girls have grown to about
95% of their adult height. They may have some additional growth (5%) until the epiphyseal plates are closed.
Although growth cannot be definitively predicted, on average, 95% of adult height has been reached with the
onset of menstruation. Pubertal growth spurt lasts about 1 year does not address the girls question. Young
women usually will grow approximately 5% more after the onset of menstruation.
PTS: 1 DIF: Cognitive Level: Apply REF: 42
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
8. A childs skeletal age is best determined by:
a.
assessment of dentition.
b.
assessment of height over time.
c.
facial bone development.
d.
radiographs of the hand and wrist.
ANS: D
The most accurate measure of skeletal age is radiologic examinations of the growth plates. These are the
epiphyseal cartilage plates. Radiographs of the hand and wrist provide the most useful screening to determine
skeletal age. Age of tooth eruption has considerable variation in children. It would not be a good determinant
of skeletal age. Assessment of height over time will provide a record of the childs height but not skeletal age.
Facial bone development will not reflect the childs skeletal age, which is determined by radiographic
assessment.
PTS: 1 DIF: Cognitive Level: Remember REF: 42
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
9. Trauma to which site can result in a growth problem for childrens long bones?
a.
Matrix
b.
Connective tissue
c.
Calcified cartilage
d.
Epiphyseal cartilage plate
ANS: D
The epiphyseal cartilage plate is the area of active growth. Bone injury at the epiphyseal plate can significantly
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affect subsequent growth and development. Trauma or infection can result in deformity. The matrix,
connective tissue, and calcified cartilage are not areas of active growth. Trauma in these sites will not result in
growth problems for the long bones.
PTS: 1 DIF: Cognitive Level: Comprehend REF: 42
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
10. A nurse has completed a teaching session for adolescents regarding lymphoid tissue growth. Which
statement, by the adolescents, indicates understanding of the teaching?
a. The tissue reaches adult size by age 1 year.
b. The tissue quits growing by 6 years of age.
c. The tissue is poorly developed at birth.
d. The tissue is twice the adult size by ages 10 to 12 years.
ANS: D
Lymphoid tissue continues growing until it reaches maximal development at ages 10 to 12 years, which is
twice its adult size. A rapid decline in size occurs until it reaches adult size by the end of adolescence. The
tissue reaches adult size at 6 years of age but continues to grow. The tissue is well developed at birth.
PTS: 1 DIF: Cognitive Level: Analyze REF: 42
TOP:Integrated Process: Nursing Process: Evaluation
MSC:Area of Client Needs: Health Promotion and Maintenance
11. Which statement is true about the basal metabolic rate (BMR) in children?
a. It is reduced by fever.
b. It is slightly higher in boys than in girls at all ages.
c. It increases with age of child.
d. It decreases as proportion of surface area to body mass increases.
ANS: B
The BMR is the rate of metabolism when the body is at rest. At all ages, the rate is slightly higher in boys than
in girls. The rate is increased by fever. The BMR is highest in infancy and then closely relates to the proportion
of surface area to body mass. As the child grows, the proportion decreases progressively to maturity.
PTS: 1 DIF: Cognitive Level: Understand REF: 43
TOP:Integrated Process: Nursing Process: Assessment
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MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
12. A mother reports that her 6-year-old child is highly active, irritable, and irregular in habits and that the
child adapts slowly to new routines, people, or situations. The nurse should chart this type of temperament as:
a.
easy.
b.
difficult.
c.
slow-to-warm.
d.
fast-to-warm.
ANS: B
Being highly active, irritable, irregular in habits, and adapting slowly to new routines, people, or situations is a
description of difficult children, which compose about 10% of the population. Negative withdrawal responses
are typical of this type of child, who requires a more structured environment. Mood expressions are usually
intense and primarily negative. These children exhibit frequent periods of crying and often violent tantrums.
Easy children are even tempered, regular, and predictable in their habits. They are open and adaptable to
change. Approximately 40% of children fit this description. Slow-to-warm-up children typically react
negatively and with mild intensity to new stimuli and adapt slowly with repeated contact. Approximately 10%
of children fit this description. Fast-to-warm-up is not one of the categories identified.
PTS: 1 DIF: Cognitive Level: Apply REF: 44
TOP:Integrated Process: Communication and Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
13. A 12-year-old child enjoys collecting stamps, playing soccer, and participating in Boy Scout activities. The
nurse recognizes that the child is displaying which developmental task?
a.
Identity
b.
Industry
c.
Integrity
d.
Intimacy
ANS: B
Industry is engaging in tasks that can be carried through to completion, learning to compete and cooperate with
others, and learning rules. Industry is the developmental task characteristic of the school-age child. Identity is
the developmental task of adolescence. Integrity and intimacy are not developmental tasks of childhood.
PTS: 1 DIF: Cognitive Level: Understand REF: 46
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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14. A nurse is conducting parenting classes for parents of children ranging in ages 2 to 7 years. The parents
understand the term egocentrism when they indicate it means:
a.
selfishness.
b.
self-centeredness.
c.
preferring to play alone.
d.
unable to put self in anothers place.
ANS: D
According to Piaget, children ages 2 to 7 years are in the preoperational stage of development. Children
interpret objects and events not in terms of their general properties but in terms of their relationships or their
use to them. This egocentrism does not allow children of this age to put themselves in anothers place.
Selfishness, self-centeredness, and preferring to play alone do not describe the concept of egocentricity.
PTS: 1 DIF: Cognitive Level: Apply REF: 47
TOP:Integrated Process: Nursing Process: Evaluation
MSC:Area of Client Needs: Health Promotion and Maintenance
15. The nurse is observing parents playing with their 10-month-old child. Which should the nurse recognize as
evidence that the child is developing object permanence?
a. Looks for the toy that parents hide under the blanket
b. Returns the blocks to the same spot on the table
c. Recognizes that a ball of clay is the same when flattened out
d. Bangs two cubes held in her hands
ANS: A
Object permanence is the realization that items that leave the visual field still exist. When the infant searches
for the toy under the blanket, it is an indication that object permanence has developed. Returning the blocks to
the same spot on the table is not an example of object permanence. Recognizing that a ball of clay is the same
when flattened out is an example of conservation, which occurs during the concrete operations stage from 7 to
11 years. Banging two cubes together is a simple repetitive activity characteristic of developing a sense of
cause and effect.
PTS: 1 DIF: Cognitive Level: Apply REF: 47
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
16. A father tells the nurse that his child is filling up the house with collections like seashells, bottle caps,
baseball cards, and pennies. The nurse should recognize that the child is developing:
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a.
object permanence.
b.
preoperational thinking.
c.
concrete operational thinking.
d.
ability to use abstract symbols.
29
ANS: C
During concrete operations, children develop logical thought processes. They are able to classify, sort, order,
and otherwise organize facts about the world. This ability fosters the childs ability to create collections. Object
permanence is the realization that items that leave the visual field still exist. This is a task of infancy and does
not contribute to collections. Preoperational thinking is concrete and tangible. Children in this age group
cannot reason beyond the observable, and they lack the ability to make deductions or generalizations.
Collections are not typical for this developmental level. The ability to use abstract symbols is a characteristic
of formal operations, which develops during adolescence. These children can develop and test hypotheses.
PTS: 1 DIF: Cognitive Level: Understand REF: 47
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
17. A visitor arrives at a daycare center during lunch time. The preschool children think that every time they
have lunch a visitor will arrive. Which preoperational characteristic is being displayed?
a.
Egocentrism
b.
Transductive reasoning
c.
Intuitive reasoning
d.
Conservation
ANS: B
Transductive reasoning is when two events occur together, they cause each other. The expectation that every
time lunch is served a visitor will arrive is descriptive of transductive reasoning. Egocentrism is the inability to
see things from any perspective than their own. Intuitive reasoning (e.g., the stars have to go to bed just as they
do) is predominantly egocentric thought. Conservation (able to realize that physical factors such as volume,
weight, and number remain the same even though outward appearances are changed) does not occur until
school age.
PTS: 1 DIF: Cognitive Level: Analyze REF: 47
TOP:Integrated Process: Nursing Process: Diagnosis
MSC:Area of Client Needs: Health Promotion and Maintenance
18. Which behavior is most characteristic of the concrete operations stage of cognitive development?
a. Progression from reflex activity to imitative behavior
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b. Inability to put oneself in anothers place
c. Increasingly logical and coherent thought processes
d. Ability to think in abstract terms and draw logical conclusions
ANS: C
During the concrete operations stage of development, which occurs approximately between ages 7 and 11
years, increasingly logical and coherent thought processes occur. This is characterized by the childs ability to
classify, sort, order, and organize facts to use in problem solving. The progression from reflex activity to
imitative behavior is characteristic of the sensorimotor stage of development. The inability to put oneself in
anothers place is characteristic of the preoperational stage of development. The ability to think in abstract
terms and draw logical conclusions is characteristic of the formal operations stage of development.
PTS: 1 DIF: Cognitive Level: Understand REF: 47
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
19. According to Kohlberg, children develop moral reasoning as they mature. Which statement is most
characteristic of a preschoolers stage of moral development?
a. Obeying the rules of correct behavior is important.
b. Showing respect for authority is important behavior.
c. Behavior that pleases others is considered good.
d. Actions are determined as good or bad in terms of their consequences.
ANS: D
Preschoolers are most likely to exhibit characteristics of Kohlbergs preconventional level of moral
development. During this stage, they are culturally oriented to labels of good or bad, right or wrong. Children
integrate these concepts based on the physical or pleasurable consequences of their actions. Obeying the rules
of correct behavior, showing respect for authority, and engaging in behavior that pleases others are
characteristics of Kohlbergs conventional level of moral development.
PTS: 1 DIF: Cognitive Level: Understand REF: 47
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
20. A school nurse notes that school-age children generally obey the rules at school. The nurse recognizes that
the children are displaying which stage of moral development?
a.
Preconventional
b.
Conventional
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c.
Post-conventional
d.
Undifferentiated
31
ANS: B
Conventional stage of moral development is described as obeying the rules, doing ones duty, showing respect
for authority, and maintaining the social order. This stage is characteristic of school-age childrens behavior.
The preconventional stage is characteristic of the toddler and preschool age. At this stage, the child has no
concept of the basic moral order that supports being good or bad. The post-conventional level is characteristic
of an adolescent and occurs at the formal stage of operation. Undifferentiated describes an infants
understanding of moral development.
PTS: 1 DIF: Cognitive Level: Analyze REF: 47
TOP:Integrated Process: Nursing Process: Evaluation
MSC:Area of Client Needs: Health Promotion and Maintenance
21. A nurse observes a toddler playing with sand and water. The nurse appropriately documents this type of
play as _____ play.
a.
skill
b.
dramatic
c.
social-affective
d.
sense-pleasure
ANS: D
The toddler playing with sand and water is engaging in sense-pleasure play. This is characterized by nonsocial
situations in which the child is stimulated by objects in the environment. Infants engage in skill play when they
persistently demonstrate and exercise newly acquired abilities. Dramatic play is the predominant form of play
in the preschool period. Children pretend and fantasize. Social-affective play is one of the first types of play in
which infants engage. The infant responds to interactions with people.
PTS: 1 DIF: Cognitive Level: Apply REF: 49
TOP:Integrated Process: Communication and Documentation
MSC:Area of Client Needs: Health Promotion and Maintenance
22. In which type of play are children engaged in similar or identical activity, without organization, division of
labor, or mutual goal?
a.
Solitary
b.
Parallel
c.
Associative
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d.
32
Cooperative
ANS: C
In associative play, no group goal is present. Each child acts according to his or her own wishes. Although the
children may be involved in similar activities, no organization, division of labor, leadership assignment, or
mutual goal exists. Solitary play describes children playing alone with toys different from those used by other
children in the same area. Parallel play describes children playing independently but being among other
children. Cooperative play is organized. Children play in a group with other children who play in activities for
a common goal.
PTS: 1 DIF: Cognitive Level: Understand REF: 50
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
23. The nurse observes some children in the playroom. Which play situation exhibits the characteristics of
parallel play?
a. Kimberly and Amanda sharing clay to each make things
b. Brian playing with his truck next to Kristina playing with her truck
c. Adam playing a board game with Kyle, Steven, and Erich
d. Danielle playing with a music box on her mothers lap
ANS: B
Playing with trucks next to each other but not together is an example of parallel play. Both children are
engaged in similar activities in proximity to each other; however, they are each engaged in their own play.
Sharing clay to make things is characteristic of associative play. Friends playing a board game together is
characteristic of cooperative play. A child playing with something by herself on her mothers lap is an example
of solitary play.
PTS: 1 DIF: Cognitive Level: Analyze REF: 50
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
24. A nurse is planning play activities for school-age children. Which type of a play activity should the nurse
plan?
a.
Solitary
b.
Parallel
c.
Associative
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d.
33
Cooperative
ANS: D
School-age children engage in cooperative play where it is organized and interactive. Playing a game is a good
example of cooperative play. Solitary play is appropriate for infants, parallel play is an activity appropriate for
toddlers, and associative play is an activity appropriate for preschool-age children.
PTS: 1 DIF: Cognitive Level: Apply REF: 51
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
25. Which following function of play is a major component of play at all ages?
a.
Creativity
b.
Socialization
c.
Intellectual development
d.
Sensorimotor activity
ANS: D
Sensorimotor activity is a major component of play at all ages. Active play is essential for muscle development
and allows the release of surplus energy. Through sensorimotor play, children explore their physical world by
using tactile, auditory, visual, and kinesthetic stimulation. Creativity, socialization, and intellectual
development are each functions of play that are major components at different ages.
PTS: 1 DIF: Cognitive Level: Understand REF: 51
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Developmental Stages and Transitions
26. Parents are asking the clinic nurse about an appropriate toy for their toddler. Which response by the nurse
is appropriate?
a. Your child would enjoy playing a board game.
b. A toy your child can push or pull would help develop muscles.
c. An action figure toy would be a good choice.
d. A 25-piece puzzle would help your child develop recognition of shapes.
ANS: B
Toys should be appropriate for the childs age. A toddler would benefit from a toy he or she could push or pull.
The child is too young for a board game, action figure, or 25-piece puzzle.
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PTS: 1 DIF: Cognitive Level: Apply REF: 52
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
27. Which is probably the single most important influence on growth at all stages of development?
a.
Nutrition
b.
Heredity
c.
Culture
d.
Environment
ANS: A
Nutrition is the single most important influence on growth. Dietary factors regulate growth at all stages of
development, and their effects are exerted in numerous and complex ways. Adequate nutrition is closely
related to good health throughout life. Heredity, culture, and environment contribute to the childs growth and
development. However, good nutrition is essential throughout the life span for optimal health.
PTS: 1 DIF: Cognitive Level: Understand REF: 43
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
28. A nurse is counseling an adolescent, in her second month of pregnancy, about the risk of teratogens. The
adolescent has understood the teaching if she makes which statement?
a. I will be able to continue taking isotretinoin (Accutane) for my acne.
b. I can continue to clean my cats litter box.
c. I should avoid any alcoholic beverages.
d. I will ask my physician to adjust my phenytoin (Dilantin) dosage.
ANS: C
Teratogens are agents that cause birth defects when present in the prenatal period. Avoidance of alcoholic
beverages is recommended to prevent fetal alcohol syndrome. Isotretinoin (Accutane) and phenytoin (Dilantin)
have been shown to have teratogenic effects and should not be taken during pregnancy. Cytomegalovirus, an
infection agent and a teratogen, can be transmitted through cat feces, and cleaning the litter box during
pregnancy should be avoided.
PTS: 1 DIF: Cognitive Level: Analyze REF: 55
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
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29. What should the nurse consider when discussing language development with parents of toddlers?
a. Sentences by toddlers include adverbs and adjectives.
b. The toddler expresses himself or herself with verbs or combination words.
c. The toddler uses simple sentences.
d. Pronouns are used frequently by the toddler.
ANS: B
The first parts of speech used are nouns, sometimes verbs (e.g., go), and combination words (e.g., bye-bye).
Responses are usually structurally incomplete during the toddler period. The preschool child begins to use
adjectives and adverbs to qualify nouns followed by adverbs to qualify nouns and verbs. Pronouns are not
added until the later preschool years. By the time children enter school, they are able to use simple, structurally
complete sentences that average five to seven words.
PTS: 1 DIF: Cognitive Level: Apply REF: 47
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
30. A nurse is observing children at play. Which figure depicts associative play?
a.
c.
b.
d.
ANS: C
The children depicted in the figure at the carnival ride are demonstrating associative play. They are engaged in
similar or identical activities. The child depicted playing alone is demonstrating solitary play. The children
playing on the beach depict parallel play. They are playing side by side but are participating in different
activities. The children depicted playing a board game are engaging in cooperative play.
PTS: 1 DIF: Cognitive Level: Analyze REF: 50
TOP:Integrated Process: Nursing Process: Evaluation
MSC:Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Play serves many purposes. In teaching parents about appropriate activities, the nurse should inform them
that play serves which of the following function? (Select all that apply.)
a.
Intellectual development
b.
Physical development
c.
Socialization
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d.
Creativity
e.
Temperament development
36
ANS: A, C, D
A common statement is that play is the work of childhood. Intellectual development is enhanced through the
manipulation and exploration of objects. Socialization is encouraged by interpersonal activities and learning of
social roles. In addition, creativity is developed through the experimentation characteristic of imaginative play.
Physical development depends on many factors; play is not one of them. Temperament refers to behavioral
tendencies that are observable from the time of birth. The actual behaviors, but not the childs temperament
attributes, may be modified through play.
PTS: 1 DIF: Cognitive Level: Understand REF: 51
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
2. What factors indicate parents should seek genetic counseling for their child? (Select all that apply.)
a.
Abnormal newborn screen
b.
Family history of a hereditary disease
c.
History of hypertension in the family
d.
Severe colic as an infant
e.
Metabolic disorder
ANS: A, B, E
Factors that are indicative parents should seek genetic counseling for their child include an abnormal newborn
screen, family history of a hereditary disease, and a metabolic disorder. A history of hypertension or severe
colic as an infant is not an indicator of a genetic disease.
PTS: 1 DIF: Cognitive Level: Understand REF: 56
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
3. A nurse is preparing to administer a Denver II. Which is a correct statement about the Denver II? (Select all
that apply.)
a. All items intersected by the age line should be administered.
b. There is no correction for a child born prematurely.
c. The tool is an intelligence test.
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d. Toddlers and preschoolers should be prepared by presenting the test as a game.
e. Presentation of the toys from the kit should be done one at a time.
ANS: A, D, E
To identify cautions, all items intersected by the age line are administered. Toddlers and preschoolers should
be tested by presenting the Denver II as a game. Because children are easily distracted, perform each item
quickly and present only one toy from the kit at a time. Before beginning the screening, ask whether the child
was born preterm and correctly calculate the adjusted age. Up to 24 months of age, allowances are made for
preterm infants by subtracting the number of weeks of missed gestation from their present age and testing them
at the adjusted age. Explain to the parents and child, if appropriate, that the screenings are not intelligence tests
but rather are a method of showing what the child can do at a particular age.
PTS: 1 DIF: Cognitive Level: Apply REF: 53
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
COMPLETION
1. The nurse is recording a normal interpretation of a Denver II assessment. The nurse understands that the
maximum number of cautions determined for a normal interpretation is _____. (Record your answer in a whole
number.)
ANS:
1
Interpretation of normal for a Denver II is no delays and a maximum of one caution.
PTS: 1 DIF: Cognitive Level: Apply REF: 53
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
ESSAY
1. Place in order the sequence of cephalocaudal development that the nurse expects to find in the infant. Begin
with the first development expected, sequencing to the final. Provide answer using lowercase letters separated
by commas (e.g., a, b, c, d).
a. Crawl
b. Sit unsupported
c. Lift head when prone
d. Gain complete head control
e. Walk
ANS:
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c, d, b, a, e
Cephalocaudal development is head-to-tail. Infants achieve structural control of the head before they have
control of their trunks and extremities, they lift their head while prone, obtain complete head control, sit
unsupported, crawl, and walk sequentially.
PTS: 1 DIF: Cognitive Level: Apply REF: 39
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
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Chapter 04: Communication and Physical Assessment of the Child
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.
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: 58
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 59
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
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: 61
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: 62
TOP:Integrated Process: Communication and Documentation
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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.
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: 62
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: 61
TOP:Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
7. A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for
this child?
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a.
Focus communication on child.
b.
Explain experiences of others to child.
c.
Use easy analogies when possible.
d.
Assure child that communication is private.
42
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: 62
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: 62
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
43
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: 63
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: 62
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.
d. Use the same type of language as the adolescent.
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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: 63
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: 65
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.
b. a way to establish rapport.
c.
too distracting, when cooperation is important.
d. acceptable, if there is adequate time.
ANS: B
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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: 63
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: 65
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.
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
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interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this
time.
PTS: 1 DIF: Cognitive Level: Apply REF: 63
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: 67
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?
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
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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: 67
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: 68
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:
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-year-old child. If pertinent, attainment of milestones by siblings would be included in the family
history. The review of systems does not include the developmental milestones.
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PTS: 1 DIF: Cognitive Level: Understand REF: 68
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: 69
TOP:Integrated Process: Nursing Process: Assessment
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: 70
TOP:Integrated Process: Nursing Process: Assessment
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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: 73
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.
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-to-toe assessment can be done in older
children but usually must be adapted in younger children. Traumatic procedures should always be performed
last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment
slowly. The child can inspect the equipment, but demonstrations are usually too complex for toddlers.
PTS: 1 DIF: Cognitive Level: Apply REF: 77
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:
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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: 78
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
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: 79
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.
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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. African-American 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: 78
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 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: 82
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
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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: 82
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: 82
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
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 83
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: 86
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: 86
TOP:Integrated Process: Nursing Process: Assessment
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
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b.
Buttocks
c.
Oral mucosa
d.
Palms and soles
54
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: 90
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: 90
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
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ANS: D
Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or
inflammation close to their location. Tender lymph nodes are not usually indicative of cancer. A scalp infection
would usually not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection
would be inflamed.
PTS: 1 DIF: Cognitive Level: Analyze REF: 91
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: 91
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
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 92
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: 92
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: 93
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
57
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: 93
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: 94
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
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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: 94
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: 93
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 99
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 5-year-old child is:
a.
the Rinne test.
b.
the Weber test.
c.
conventional audiometry.
d.
eliciting the startle reflex.
ANS: C
Conventional audiometry is a behavioral test that measures auditory thresholds in response to speech and
frequency-specific stimuli presented through earphones. The Rinne and Weber tests measure bone conduction
of sound. Eliciting the startle reflex may be useful in infants.
PTS: 1 DIF: Cognitive Level: Understand REF: 98
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: 102
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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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: 103
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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: 103
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.
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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: 104
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
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: 105
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.
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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: 105
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: 97
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?
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
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should always be provided for children.
PTS: 1 DIF: Cognitive Level: Understand REF: 109
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 knock-knee.
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 African-American children.
PTS: 1 DIF: Cognitive Level: Understand REF: 110
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
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: 110
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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56. A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the finger-tonose 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: 111
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: 111
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup.
What criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that
apply.)
a. The cuff is labeled toddler.
b. The cuff bladder width is approximately 40% of the circumference of the upper arm.
c. The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
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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: 87
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: 66
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
b.
Edema
c.
Pruritus
d.
Jaundice
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e.
66
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: 75
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
4. A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient
and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that
apply.)
a. Elicit one answer at a time.
b. Interrupt the interpreter if the response from the family is lengthy.
c. Comments to the interpreter about the family should be made in English.
d. Arrange for the family to speak with the same interpreter, if possible.
e. Introduce the interpreter to the family.
ANS: A, D, E
When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: Do you
have pain? rather than Do you have any pain, tiredness, or loss of appetite? Refrain from interrupting family
members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time
before the interview for them to become acquainted. Refrain from interrupting family members and the
interpreter while they are conversing. Avoid commenting to the interpreter about family members because they
may understand some English.
PTS: 1 DIF: Cognitive Level: Apply REF: 61
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
ESSAY
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 114
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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Chapter 05: Pain Assessment and Management in Children
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: 115
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. The nurse is caring for a 6-year-old girl who had surgery 12 hours ago. The child tells the nurse that she
does not have pain, but a few minutes later she tells her parents that she does. Which should the nurse consider
when interpreting this?
a.
Truthful reporting of pain should occur by this age.
b.
Inconsistency in pain reporting suggests that pain is not present.
c.
Children use pain experiences to manipulate their parents.
d.
Children may be experiencing pain even though they deny it to the nurse.
ANS: D
Children may deny pain to the nurse because they fear receiving an injectable analgesic or because they
believe they deserve to suffer as a punishment for a misdeed. They may refuse to admit pain to a stranger but
readily tell a parent. Truthfully reporting pain and inconsistency in pain reporting suggesting that pain is not
present are common fallacies about children and pain. Pain is whatever the experiencing person says it is,
whenever the person says it exists. Pain would not be questioned in an adult 12 hours after surgery.
PTS: 1 DIF: Cognitive Level: Analyze REF: 115
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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: 121
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 115
TOP: Integrated Process: Nursing Process: Assessment
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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: 129
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: 132
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
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this procedure is to apply _____ before the procedure.
a.
TAC (tetracaine-adrenaline-cocaine) 15 minutes
b.
transdermal fentanyl (Duragesic) patch immediately
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: 137
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: 139
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
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should the nurse use with a child this age?
a.
b.
c.
d.
ANS: A
The pain scale appropriate for a 4-year-old child is the FACES pain scale. Numeric pain scales can be used on
children as young as age 5 as long as they can count and have some concept of numbers and their values in
relation to other numbers. Word graphic scales and visual analogue scales are used preferably for school-age
children.
PTS: 1 DIF: Cognitive Level: Analyze REF: 117
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: 123
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
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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: 123
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.)
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: 135
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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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: 137
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: 134
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following
assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability:
content, relaxed. The nurse records the FLACC assessment as which number? (Record your answer as a whole
number.)
ANS:
2
The FLACC scale is recorded per the following table:
0
1
2
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Face
No
particular
expression
or smile
Legs
Normal
Uneasy,
position restless,
or relaxed tense
Activity
Lying
quietly,
normal
position,
moves
easily
Cry
Moans or
No cry
(awake or whimpers,
asleep)
occasional
complaint
Consolability Content,
relaxed
Occasional
grimace or
frown,
withdrawn,
disinterested
75
Frequent
to constant
frown,
clenched
jaw,
quivering
chin
Kicking or
legs drawn
up
Squirming, Arched,
shifting
rigid, or
back and
jerking
forth, tense
Crying
steadily,
screams or
sobs,
frequent
complaints
Reassured Difficult
by
to console
occasional or comfort
touching,
hugging, or
talking to;
distractible
Because the child has a grimace and is squirming and tense, 2 total points are given. Relaxed legs, no cry, and
content and relaxed consolability get 0 points.
PTS: 1 DIF: Cognitive Level: Apply REF: 118
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.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 142
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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Chapter 06: Childhood Communicable and Infectious Diseases
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: 152
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 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: 152
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: 152
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?
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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: 156
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 157
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: 158
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: 159
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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: 159
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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: 159
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: 160
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 160
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
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: 160
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: 160
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: 161
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
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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: 161
TOP: Integrated Process: Nursing Process: Implementation
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: 163
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: 165
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: 168
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: 168
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: 166
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: 166
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:
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.
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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: 167
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: 167
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 tick-infested 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: 170
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:
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: 173
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
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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: 173
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: 172
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.
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: 173
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 174
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: 177
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.
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: 178
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: 189
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
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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 fourthdegree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone.
PTS: 1 DIF: Cognitive Level: Understand REF: 180
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.
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: 181
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: 181
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: 181
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 181
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: 182
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: 182
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.
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ANS: B
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: 182
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 high-protein 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: 183
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: 183
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: 183
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?
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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: 184
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: 184
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 partial-thickness 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: 184
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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: 187
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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: 187
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 infection-control program.
Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the
wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to
remain in place but not so tightly as to impair circulation or limit motion.
PTS: 1 DIF: Cognitive Level: Apply REF: 186
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.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 189
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.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 176
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).
PTS: 1 DIF: Cognitive Level: Apply REF: 171
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?
a. c.
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Chapter 07: Health Promotion of the Newborn and Family
MULTIPLE CHOICE
1. Which is the most critical physiologic change required of the newborn?
a.
Closure of fetal shunts in the heart
b.
Stabilization of fluid and electrolytes
c.
Body-temperature maintenance
d.
Onset of breathing
ANS: D
The onset of breathing is the most immediate and critical physiologic change required for transition to
extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition
of hypoxemia, hypercapnia, and acidosis. This affects the fetuss adjustment to extrauterine life. Closure of fetal
shunts in the heart, stabilization of fluid and electrolytes, and body-temperature maintenance are important
changes that must occur in the transition to extrauterine life, but breathing and the exchange of oxygen for
carbon dioxide must come first.
PTS: 1 DIF: Cognitive Level: Understand REF: 191
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which is a function of brown adipose tissue (BAT) in the newborn?
a.
Provides ready source of calories in the newborn period
b.
Insulates the body against lowered environmental temperature
c.
Protects the newborn from injury during the birth process
d.
Generates heat for distribution to other parts of body
ANS: D
Brown fat is a unique source of heat for the newborn. It has a larger content of mitochondrial cytochromes and
a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue.
Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective in heat
production only. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of
heat. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and
behind the sternum. These areas would not protect the newborn from injury during the birth process.
PTS: 1 DIF: Cognitive Level: Understand REF: 191
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which characteristic is representative of the newborns gastrointestinal tract?
a.
Stomach capacity is approximately 90 ml.
b.
Peristaltic waves are relatively slow.
c.
Overproduction of pancreatic amylase occurs.
d.
Intestines are shorter in relation to body size.
ANS: A
Newborns require frequent small feedings because their stomach capacity is approximately 90 ml. Peristaltic
waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats. Newborns intestines are longer
in relation to body size than those of an adult.
PTS: 1 DIF: Cognitive Level: Understand REF: 192
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of
stool?
a.
Meconium
b.
Transitional
c.
Miliaria
d.
Milk stool
ANS: A
Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and
possibly blood. It is the newborns first stool. Transitional stools usually appear by the third day after the
beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than
meconium. Miliaria are distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool
usually occurs by the fourth day. The appearance varies, depending on whether the neonate is breast-fed or
formula-fed.
PTS: 1 DIF: Cognitive Level: Remember REF: 192
TOP: Integrated Process: Nursing Process: Assessment
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MSC: Area of Client Needs: Health Promotion and Maintenance
5. A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse documents this
finding and continues to monitor the newborn because, in term newborns, the first meconium stool occurs
within how many hours of birth?
a.
6 to 8
b.
8 to 12
c.
12 to 24
d.
24 to 48
ANS: D
The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to 7 days in very
lowbirth-weight newborns. Although it may occur earlier, the expected range is the first 24 to 48 hours of life.
PTS: 1 DIF: Cognitive Level: Remember REF: 192
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A nurse is doing an assessment on a newborn. Which is characteristic of a newborns vision at birth and an
expected finding during the assessment?
a.
Ciliary muscles are mature.
b.
Blink reflex is absent.
c.
Tear glands function.
d.
Pupils react to light.
ANS: D
Although at birth the eye is still structurally incomplete, the pupils do react to light. The ciliary muscles are
immature, limiting the eyes ability to focus on an object for any length of time. The blink reflex is responsive
to minimal stimulus. The tear glands do not begin to function until ages 2 to 4 weeks.
PTS: 1 DIF: Cognitive Level: Remember REF: 193
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. The Apgar score of a newborn 5 minutes after birth is 8. Which is the nurses best interpretation of this?
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a.
Resuscitation is likely to be needed.
b.
Adjustment to extrauterine life is adequate.
c.
Additional scoring in 5 more minutes is needed.
d.
Maternal sedation or analgesia contributed to the low score.
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ANS: B
The Apgar reflects the newborns status in five areas: heart rate, respiratory effort, muscle tone, reflex
irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting to extrauterine life. Scores of
0 to 3 indicate severe distress, and scores of 4 to 6 indicate moderate difficulty. The Apgar score is not used to
determine the newborns need for resuscitation at birth. All newborns are rescored at 5 minutes. The newborn
does not have a low score.
PTS: 1 DIF: Cognitive Level: Understand REF: 194
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. The nurse is presenting an in-service session on assessing gestational age in newborns. Which information
should be included?
a.
The newborns length and weight are the most accurate indicators of gestational age.
b.
The newborns Apgar score and the mothers estimated date of confinement (EDC) are combined to
determine gestational age.
c.
The newborns posture at rest and arm recoil are two physical signs used to determine gestational age.
d.
The newborns chest circumference compared to the head circumference is the determinant for gestational
age.
ANS: C
With the newborn quiet and in a supine position, the degree of flexion in the arms and legs and the arm recoil
can be used to help determine gestational age. Length, weight, and the chest/head circumference reflect the
newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of
gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine
life, and the mothers EDC is of no importance in determining gestational age.
PTS: 1 DIF: Cognitive Level: Apply REF: 194
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. The nurse is assessing a 3-day-old, breast-fed newborn who weighed 7 pounds, 8 ounces at birth. The
newborns mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most
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appropriate nursing intervention?
a.
Recommend supplemental feedings of formula.
b.
Explain that this weight loss is within normal limits.
c.
Assess child further to determine cause of excessive weight loss.
d.
Encourage mother to express breast milk for bottle feeding the newborn.
ANS: B
The newborn normally loses about 10% of the birth weight by age 3 or 4 days. The birth weight is usually
regained by the tenth day of life. Because this is an expected occurrence, no further action is needed. The
mother should be taught about normal newborn feeding and growing patterns.
PTS: 1 DIF: Cognitive Level: Apply REF: 197
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. Why are rectal temperatures not recommended in the newborn?
a.
They are inaccurate.
b.
They do not reflect core body temperature.
c.
They can cause perforation of rectal mucosa.
d.
They take too long to obtain an accurate reading.
ANS: C
Rectal temperatures are avoided in the newborn. If done incorrectly, the insertion of a thermometer into the
rectum can perforate the mucosa. Rectal temperatures, if taken correctly, are considered an accurate reflection
of core body temperature. The inherent risks and intrusive nature limit the use. The time it takes to determine
body temperature is related to the equipment used, not the route only.
PTS: 1 DIF: Cognitive Level: Remember REF: 197
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
a.
60 to 80 beats/min
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b.
80 to 100 beats/min
c.
120 to 140 beats/min
d.
160 to 180 beats/min
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ANS: C
The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140
beats/min; 60 to 100 beats/min is too slow for a neonate and 160 to 180 beats/min is too fast for a neonate.
PTS: 1 DIF: Cognitive Level: Remember REF: 198
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. A nurse is palpating a newborns fontanels. The nurse documents the anterior fontanel is which shape?
a.
Circle
b.
Triangle
c.
Square
d.
Diamond
ANS: D
The anterior fontanel is diamond-shaped and measures from barely palpable to 4 to 5 cm. Neither of the
fontanels is a circle or a square. The triangle is the shape of the posterior fontanel.
PTS: 1 DIF: Cognitive Level: Understand REF: 201
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
13. Which is the name of the suture separating the parietal bones at the top center of a newborns head?
a.
Frontal
b.
Coronal
c.
Sagittal
d.
Occipital
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ANS: C
The sagittal suture separates the parietal bones on top of the newborns head. The frontal suture separates the
frontal bones. The coronal suture is said to crown the head. There is no occipital suture. The lambdoid suture is
at the margin of the parietal and occipital bones.
PTS: 1 DIF: Cognitive Level: Remember REF: 200
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
14. In a newborns eyes, strabismus is a normal finding because of:
a.
congenital cataracts.
b.
lack of binocularity.
c.
absence of red reflex.
d.
inability of pupil to react to light.
ANS: B
Newborns are unable to focus their eyes on an object. Binocularity does not develop until ages 3 to 4 months.
Congenital cataracts, absence of red reflex, and inability of pupil to react to light are not normal findings and
need further evaluation.
PTS: 1 DIF: Cognitive Level: Understand REF: 202
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A nurse has determined that a newborns respiratory breathing is within a normal range. How should the
nurse document this finding?
a.
Irregular, abdominal, 30 to 60 breaths/min
b.
Regular, abdominal, 25 to 35 breaths/min
c.
Regular, noisy, 35 to 45 breaths/min
d.
Irregular, quiet, 45 to 55 breaths/min
ANS: A
The respirations of a normal newborn are irregular and abdominal, with a rate of 30 to 60 breaths/min.
Newborn respirations are irregular. Pauses in respiration less than 20 seconds in duration are considered
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normal. The newborn is an abdominal breather with a wider range of respiratory rates.
PTS: 1 DIF: Cognitive Level: Understand REF: 202
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
16. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous,
and pendulous. This should be interpreted as a(n):
a.
normal finding.
b.
hydrocele.
c.
absence of testes.
d.
inguinal hernia.
ANS: A
A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is
a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few
months. The presence or absence of testes would be determined on palpation of the scrotum and inguinal canal.
Absence of testes may be an indication of ambiguous genitalia. An inguinal hernia may be present at birth. It is
more easily detected when the child is crying.
PTS: 1 DIF: Cognitive Level: Apply REF: 204
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Stroking the newborns cheek along the side of the mouth causes the newborn to turn the head toward that
side and begin to suck. This is which reflex?
a.
Perez
b.
Sucking
c.
Rooting
d.
Extrusion
ANS: C
Stroking the newborns cheek along the side of the mouth causes the newborn to turn the head toward that side
and begin to suck is a description of the rooting reflex, which usually disappears by ages 3 to 4 months but
may persist for up to 12 months. The Perez reflex involves stroking the newborns back when prone; the child
flexes extremities, elevating head and pelvis. It disappears at ages 4 to 6 months. The newborn begins strong
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sucking movements in response to circumoral stimulation. The reflex persists throughout infancy, even without
stimulation. Newborns force their tongues outward, when the tongue is touched or depressed. This reflex
usually disappears by age 4 months.
PTS: 1 DIF: Cognitive Level: Understand REF: 202
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Which statement best represents the first stage of the first period of reactivity in the newborn?
a.
It begins when the newborn awakes from a deep sleep.
b.
It ends when the amount of respiratory mucus has decreased.
c.
It is an excellent time to acquaint the parents with the newborn.
d.
It is an excellent time for mother to sleep and recover.
ANS: C
During the first period of reactivity, the newborn is alert, cries vigorously, may suck the fist greedily, and
appears interested in the environment. The newborns eyes are usually wide open, suggesting that this is an
excellent opportunity for mother, father, and child to see each other. The second period of reactivity begins
when the newborn awakens from a deep sleep. The second period of reactivity ends when the amount of
respiratory mucus has decreased. The mother should sleep and recover during the second stage, when the
newborn is sleeping.
PTS: 1 DIF: Cognitive Level: Understand REF: 206
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
19. The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should
perform which action?
a.
Examine newborns eyes for ability to focus.
b.
Assess for other attachment behaviors.
c.
Recognize this as a common reaction in new mothers.
d.
Ask mother why she wont look at newborn.
ANS: B
Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and the
mother. The mothers failure to make eye contact with her newborn may indicate difficulties with the formation
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of emotional bonds. The nurse should perform a more thorough assessment. Newborns do not have
binocularity and cannot focus. It is uncommon for a mother to avoid making eye contact with her newborn and
it is confrontational to ask why; this would put the mother in a defensive position.
PTS: 1 DIF: Cognitive Level: Apply REF: 207
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
20. At the time of birth, what is the grayish white, cheeselike substance that normally covers the newborns skin
called?
a.
Miliaria
b.
Meconium
c.
Amniotic fluid
d.
Vernix caseosa
ANS: D
The grayish white, cheeselike substance that normally covers the newborns skin is the vernix caseosa. Miliaria
are distended sweat glands that appear as minute vesicles. Meconium is the newborns first stool. Amniotic
fluid is produced in utero.
PTS: 1 DIF: Cognitive Level: Remember REF: 199
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
21. What are distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the
newborn period called?
a.
Milia
b.
Lanugo
c.
Mongolian spots
d.
Cutis marmorata
ANS: A
Distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period
are milia, which are common variations found in newborns. Lanugo is fine downy hair. Mongolian spots are
irregular areas of deep blue pigmentation, usually in the sacral and gluteal areas. Cutis marmorata is transient
mottling when the newborn is exposed to decreased body temperatures.
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PTS: 1 DIF: Cognitive Level: Remember REF: 208
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
22. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
a.
Feet and hands
b.
Bridge of nose
c.
Circumoral area
d.
Mucous membranes
ANS: A
Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns. Cyanosis present at
the bridge of the nose, the circumoral area, and the mucous membranes is a potential sign of distress or major
abnormality.
PTS: 1 DIF: Cognitive Level: Analyze REF: 204
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
23. What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African,
Asian, Native American, or Hispanic descent?
a.
Acrocyanosis
b.
Erythema toxicum
c.
Mongolian spots
d.
Harlequin color changes
ANS: C
Irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native
American, or Hispanic descent are Mongolian spots, which are common variations found in newborns of
African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet that is a
usual finding in newborns. Erythema toxicum is a pink papular with vesicles that may appear in 24 to 48 hours
and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the
newborn lies on one side, the lower half of the body becomes pink and the upper half is pale.
PTS: 1 DIF: Cognitive Level: Understand REF: 208
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
24. The nurse observes flaring of nares in a newborn. This should be interpreted as:
a.
nasal occlusion.
b.
sign of respiratory distress.
c.
common response to sneezing.
d.
snuffles of congenital syphilis.
ANS: B
Nasal flaring is an indication of respiratory distress. A nasal occlusion would prevent the child from breathing
through the nose. Because newborns are obligatory nose breathers, this would require immediate referral.
Sneezing and thin white mucus drainage are common in newborns and are not related to nasal flaring. Snuffles
are indicated by a thick, bloody, nasal discharge without sneezing.
PTS: 1 DIF: Cognitive Level: Understand REF: 212
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
25. A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
a.
Nystagmus
b.
Profuse drooling
c.
Dark green or black stools
d.
Slight vaginal reddish discharge
ANS: B
Profuse drooling or salivation is a potential sign of a major abnormality. Newborns with esophageal atresia
cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement
of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or
black. Pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal
discharge.
PTS: 1 DIF: Cognitive Level: Understand REF: 209
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
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26. Which is most important in the immediate care of the newborn?
a.
Maintain patent airway.
b.
Maintain stable body temperature.
c.
Administer prophylactic eye care.
d.
Establish identification of mother and baby.
ANS: A
Maintaining a patent airway is the primary objective in the care of the newborn. The nurse uses a bulb syringe
to clear the pharynx, followed by the nasal passages. Conserving the newborns body heat and maintaining a
stable body temperature are important, but a patent airway must be established first. These are important
functions, but physiologic stability is the first priority in the immediate care of the newborn.
PTS: 1 DIF: Cognitive Level: Analyze REF: 211
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
27. The nurse is careful to place the incubator away from cold windows or air-conditioning units. This is to
conserve the newborns body heat by preventing heat loss through:
a.
radiation.
b.
conduction.
c.
convection.
d.
evaporation.
ANS: A
Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner
will cool the incubator walls and subsequently the newborns body. Conduction involves the loss of heat from
the body because of direct contact of the skin with a cooler object. Convection is the loss of heat similar to
conduction but aided by air currents. Evaporation is the loss of heat through moisture. The newborn should be
quickly dried of the amniotic fluid.
PTS: 1 DIF: Cognitive Level: Apply REF: 212
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
28. Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by
explaining phytonadione (vitamin K) is administered to the newborn to:
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a.
prevent bleeding.
b.
enhance immune response.
c.
prevent bacterial infection.
d.
maintain nutritional status.
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ANS: A
Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is synthesized by the
intestinal flora. Because the newborns intestine is sterile and breast milk is low in vitamin K, a supplemental
source must be supplied. The purpose is not to enhance the immune response, prevent bacterial infection, or
maintain nutritional status. The major function of vitamin K is to catalyze the liver synthesis of prothrombin,
which is needed for blood clotting and coagulation.
PTS: 1 DIF: Cognitive Level: Apply REF: 213
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
29. In the newborn, intramuscular phytonadione (vitamin K) is administered into which muscle?
a.
Deltoid
b.
Dorsogluteal
c.
Vastus medialis
d.
Vastus lateralis
ANS: D
The vastus lateralis is the traditionally recommended injection site. The deltoid and dorsogluteal sites are not
recommended for the vitamin K administration. The ventrogluteal may be used as an alternative site to the
vastus lateralis. The vastus medialis is not used for intramuscular injections.
PTS: 1 DIF: Cognitive Level: Apply REF: 213
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
30. Recommendations for hepatitis B (HBV) vaccine include which statement?
a.
First dose is given between birth and age 2 days.
b.
First dose is given between ages 12 and 15 months.
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c.
It is not recommended for neonates who are at low risk for hepatitis B.
d.
It is not recommended for neonates whose mothers are positive for HBV surface antigen.
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ANS: A
To reduce the incidence of HBV in children and its serious consequences in adulthood, the first of three doses
is recommended soon after birth and before hospital discharge. Between 12 and 15 months is too late. The
recommendation is for the first dose to be given soon after birth. It is recommended for all newborns.
Newborns born to mothers who are HBV surface antigen positive should be given the vaccine within 12 hours
of birth. They also should be given hepatitis B immune globulin.
PTS: 1 DIF: Cognitive Level: Understand REF: 214
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
31. A newborn is being discharged at age 48 hours. The parents ask how the newborn should be bathed this
first week home. The nurses best recommendation is to bathe the newborn:
a.
daily with mild soap.
b.
daily with an alkaline soap.
c.
two or three times this week with plain water.
d.
two or three times this week with mild soap.
ANS: C
The newborn newborns skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The
parents should be taught to use only plain warm water for the bath and to bathe the child no more than two or
three times a week for the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the childs skin,
providing a medium for bacterial growth.
PTS: 1 DIF: Cognitive Level: Apply REF: 214
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
32. The stump of the umbilical cord usually separates in how many days?
a.
3
b.
10 to 14
c.
16 to 20
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28
ANS: B
The average cord separates in 10 to 14 days; 3 days is too soon and 16 to 28 days is too late. The cord should
be separated by these times.
PTS: 1 DIF: Cognitive Level: Remember REF: 216
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
33. The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this
procedure. The nurses response should be based on the knowledge that newborns:
a.
experience pain with circumcision.
b.
do not experience pain with circumcision.
c.
quickly forget about the pain of circumcision.
d.
are too young for anesthesia or analgesia.
ANS: A
Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that, when
circumcision is performed, procedural analgesia be provided. Pain is associated with surgical procedures. The
newborn experiences pain, which can be alleviated with analgesia. Topical and injected analgesia are available
for this procedure.
PTS: 1 DIF: Cognitive Level: Apply REF: 217
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
34. Early this morning, a baby boy was circumcised by using the Plastibell method. The nurse should tell the
mother that the baby can be discharged after:
a.
the newborn voids.
b.
receiving vitamin K.
c.
yellow exudate forms over glans.
d.
the Plastibell rim falls off.
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ANS: A
The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2 hours. After these
observations and voiding, the newborn can be discharged. The newborn should have received vitamin K soon
after delivery. This normal yellow exudate will usually form on the second day after the circumcision.
Discharge can occur earlier. The Plastibell rim will separate and fall off within 5 to 8 days. The newborn
should be discharged before this.
PTS: 1 DIF: Cognitive Level: Apply REF: 217
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
35. The American Academy of Pediatrics recommends that the best form of newborn nutrition is:
a.
exclusive breastfeeding until age 2 months.
b.
exclusive breastfeeding until at least age 1 year.
c.
commercially prepared newborn formula for 1 year.
d.
commercially prepared newborn formula until age 4 to 6 months.
ANS: B
The American Academy of Pediatrics has reaffirmed its position that a newborn be breastfed exclusively for
the first year of life. This group also supports programs that enable women to return to work and continue
breastfeeding. Two months is too short of a period. The recommendation is for breastfeeding, not commercial
formula. If the mother has stopped breastfeeding, then commercial formula, rather than whole milk, should be
used until age 1 year.
PTS: 1 DIF: Cognitive Level: Understand REF: 219
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
36. Successful breastfeeding is most dependent on the:
a.
mothers socioeconomic level.
b.
size of mothers breasts.
c.
mothers desire to breastfeed.
d.
birth weight of newborn.
ANS: C
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The factors that contribute to successful breastfeeding are the mothers desire to breastfeed, satisfaction with
breastfeeding, and available support systems. The mothers socioeconomic level may affect the mothers need to
return to work and available support systems, but with support, the mother can be successful. The size of the
mothers breasts does not affect the success of breastfeeding. Very lowbirth-weight newborns may be unable to
breastfeed. The mother can express milk, and it can be used for the child.
PTS: 1 DIF: Cognitive Level: Apply REF: 221
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
37. A nursing intervention to promote parent-newborn attachment should include:
a.
delaying parent-newborn interactions until the second period of reactivity.
b.
explaining individual differences among newborns to the parents.
c.
alleviating stress for parents by decreasing their participation in the newborns care.
d.
allowing a newborn to fuss for a period of time before soothing by holding.
ANS: B
Nurses can positively influence the attachment of parent and child by recognizing and explaining individual
differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the
uniqueness of each newborn. The nurse should facilitate parent-newborn interaction during the first period of
reactivity. Decreasing the parents participation in care will interfere with parent-newborn attachment. The
parents should be encouraged to hold the newborn when he or she is fussy and learn how best to soothe their
newborn.
PTS: 1 DIF: Cognitive Level: Apply REF: 224
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
38. A new mother wants to be discharged with her newborn as soon as possible. Before discharge, the nurse
should make certain that:
a.
newborn has voided at least once.
b.
newborn does not spit up after feeding.
c.
jaundice, if present, appeared before 24 hours.
d.
appointment is made for home care or a primary care practitioner office visit within next 2 or 3 days.
ANS: D
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The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care
within 48 hours of a short stay in either a primary practitioners office or the home. The child should void every
4 to 6 hours. Spitting up small amounts after feeding is a normal occurrence in newborns. It would not delay
discharge. Jaundice within the first 24 hours of life must be evaluated.
PTS: 1 DIF: Cognitive Level: Apply REF: 227
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
39. Nursing interventions to maintain a patent airway in a newborn should include:
a.
sleeping in the prone (on abdomen) position.
b.
wrapping neonate as snugly as possible.
c.
positioning neonate supine while sleeping.
d.
using bulb syringe to suction as needed, suctioning nose first, and then pharynx.
ANS: C
Supine is the position recommended by the American Academy of Pediatrics to prevent sudden infant death
syndrome. Sleeping in the prone position is not advised because of the possible link between sleeping in the
prone position and sudden infant death syndrome. The child can be wrapped snugly, but should be placed on
side or back. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned
before the nose.
PTS: 1 DIF: Cognitive Level: Apply REF: 211
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
40. A nurse is assessing the presence of expected reflexes in a newborn. Which figure depicts the elicitation of
the tonic neck reflex?
a.
c.
b.
d.
ANS: B
The tonic neck reflex is elicited when the newborns head is turned to one side; the arm and leg extend on that
side, and opposite arm and leg flex (fencing position). The Moro reflex is elicited by sudden jarring or change
in equilibrium. The newborn has extension and abduction of extremities and fanning of fingers, with index
finger and thumb forming a C shape followed by flexion and adduction of extremities; legs may weakly flex.
The dancing reflex is elicited when the newborn is held so that the sole of the foot touches a hard surface; there
is a reciprocal flexion and extension of the leg, simulating walking. The crawl reflex is elicited when the
newborn is placed on the abdomen; the newborn makes crawling movements with arms and legs.
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PTS: 1 DIF: Cognitive Level: Analyze REF: 203
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications for
breastfeeding? (Select all that apply.)
a.
Human immunodeficiency virus (HIV) in mother
b.
Mastitis
c.
Inverted nipples
d.
Maternal cancer therapy
e.
Twin births
ANS: A, D
HIV in the mother and maternal cancer therapy place the newborn at risk. HIV can be transmitted through
breast milk, as can be the metabolites of chemotherapy. Mastitis, inverted nipples, and twin births are not
contraindications.
PTS: 1 DIF: Cognitive Level: Apply REF: 220
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse is conducting discharge teaching for parents of a newborn. The nurse instructs the parents on which
method of care for the umbilical cord? (Select all that apply.)
a.
Covering the cord with the diaper
b.
Cleansing the cord with water daily
c.
Keeping the cord area free of urine and stool
d.
Monitoring for signs of infection
e.
Applying bacitracin ointment to the cord daily
ANS: B, C, D
Parents are taught to keep the cord area free of urine and stool, cleanse daily with water if needed, and observe
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for any signs of infection. The diaper should not cover the cord. The diaper is folded in front below the cord to
avoid irritation and wetness on the site. Bacitracin ointment should not be applied because the cord area should
be kept dry, not moist.
PTS: 1 DIF: Cognitive Level: Apply REF: 216
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the
nurse include in the teaching session? (Select all that apply.)
a.
Limiting the feeding to 15 minutes
b.
Propping the bottle for night feedings is acceptable
c.
Proper technique for cleansing the bottles and nipples
d.
Feeding infant on alternate sides of the lap
e.
Use of bottled water without fluoride should be avoided to mix powdered formula.
ANS: C, D, E
Parents preparing infant formula must wash their hands well and then wash all of the equipment used to
prepare the formula (including the cans of formula) with soap and water. Sterilizing bottles and nipples 5
minutes in boiling water may be required when a hot-water dishwasher is not available. Similar to breastfed
infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli.
Bottled water should not be considered sterile unless otherwise indicated; bottled water without fluoride should
be avoided for mixing infant formula. Propping the bottle during infant feedings at night time could cause the
infant to aspirate. The feeding should not be hurried. Even though they may suck vigorously for the first 5
minutes and seem to be satisfied, infants should be allowed to continue sucking. Infants need at least 2 hours of
sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provide for
oral gratification.
PTS: 1 DIF: Cognitive Level: Apply REF: 222
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is
term if which findings are assessed? (Select all that apply.)
a.
Posture with fully flexed arms and legs
b.
Arm recoil brisk
c.
Square window at 90 degrees
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Scarf sign of elbow crossing over the midline
e.
Popliteal angle less than 90 degrees
113
ANS: A, B, E
A term newborn will have a posture that is fully flexed (arms and legs) and a brisk arm recoil. The popliteal
angle in a term infant is less than 90 degrees. The square window should show no angle, the hand should lie
flat on the ventral surface of the arm in the term newborn. In a term newborn, the elbow should not cross the
midline during assessment of the scarf sign.
PTS: 1 DIF: Cognitive Level: Analyze REF: 195
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
SHORT ANSWER
1. A nurse is performing a 1-minute Apgar on a newborn. The nurse assesses that the newborn has a heart rate
over 100, a good strong cry, some flexion of extremities, sneezes, and has a pink body with blue extremities.
The nurse records what number as the Apgar? Record your answer in a whole number.
ANS:
8
0
Heart rate
1
Absent Slow,
>100
<100
beats/min
beats/min
Respiratory Absent Irregular,
effort
slow,
weak cry
Muscle
tone
Limp
Blue,
pale
Good,
strong cry
Some
Well
flexion of flexed
extremities
Reflex
No
Grimace
irritability response
Color
2
Cry, sneeze
Body
Completely
pink,
pink
extremities
blue
The newborn gets 2 for heart rate, 2 for respiratory effort, 1 for muscle tone, 2 for reflex irritability and 1 for
color = 8
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PTS: 1 DIF: Cognitive Level: Apply REF: 194
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is preparing to administer a prescribed phytonadione (vitamin K) injection 0.5 mg intramuscularly
to a newborn. The phytonadione (vitamin K) ampule is labeled 1 mg equals 0.5 ml. How many milliliters will
the nurse administer? Record your answer using two decimal places.
ANS:
0.25
Formula:
Desired
Available Volume =
0.5 mg
1 mg 0.5 mL = 0.25 mL
PTS: 1 DIF: Cognitive Level: Apply REF: 213
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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Chapter 08: Health Problems of Newborns
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: 230
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: 231
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The parents of a newborn ask the nurse what caused the 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
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: 232
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:
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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: 233
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. What is oral candidiasis (thrush) in the newborn?
a. Bacterial infection that is life threatening in the neonatal period
b. Bacterial infection of mucous membranes that responds readily to treatment
c. Yeastlike fungal infection of mucous membranes that is relatively common
d. Benign disorder that is transmitted from mother to newborn during the birth process only
ANS: C
Oral candidiasis, characterized by white adherent patches on the tongue, palate, and inner aspects of the
cheeks, is not uncommon in newborns. Candida albicans is the usual causative organism. Oral candidiasis is
usually a benign disorder in the newborn, often confined to the oral and diaper regions. It is caused by a
yeastlike organism and is treated with good hygiene, application of a fungicide, and correction of any
underlying disorder. Thrush can be transmitted in several ways, including by maternal transmission during
delivery; person-to-person transmission; and contaminated bottles, hands, or other objects.
PTS: 1 DIF: Cognitive Level: Understand REF: 233
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 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: 234
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.
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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: 235
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. 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: 235
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Which term refers to a newborn born before completion of week 37 of gestation, regardless of birth weight?
a. Postterm
b. Premature
c. Low birth weight
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 lowbirthweight newborn is a child whose birth weight is less than 2500 g, regardless of gestational age. A small-forgestational-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.
PTS: 1 DIF: Cognitive Level: Remember REF: 237
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 lowbirthweight newborn is a child whose birth weight is less than 2500 g, regardless of gestational age.
PTS: 1 DIF: Cognitive Level: Remember REF: 237
TOP: Integrated Process: Nursing Process: Assessment
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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: 241
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
12. The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes
blanching of the feet. Which is the most appropriate nursing action?
a. Elevate feet 15 degrees.
b. Place socks on newborn.
c. Wrap feet loosely in prewarmed blanket.
d. Report findings immediately to the practitioner.
ANS: D
Blanching of the feet, in a newborn with an umbilical catheter, is an indication of vasospasm. Vasoconstriction
of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency
situation and must be reported immediately.
PTS: 1 DIF: Cognitive Level: Apply REF: 241
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: 241
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. Which is the most appropriate nursing action when intermittently gavage-feeding a preterm newborn?
a. Allow formula to flow by gravity.
b. Insert tube through nares rather than mouth.
c. Avoid letting newborn suck on tube.
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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: 243
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
15. A healthy, stable, preterm newborn will soon be discharged. The nurse should recommend which position
for sleep?
a. Prone
b. Supine
c. Side lying
d. Position of comfort
ANS: B
The American Academy of Pediatrics recommends that healthy newborns be placed to sleep in a supine
position. Other positions are associated with sudden infant death syndrome. The prone position can be used for
supervised play.
PTS: 1 DIF: Cognitive Level: Apply REF: 245
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: 245
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
17. Which is an important nursing action related to the use of tape and/or adhesives on 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.
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PTS: 1 DIF: Cognitive Level: Analyze REF: 245
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
18. The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital
signs and changing the 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: 248
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: 249
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
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 252
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
21. The nurse is planning care for a family expecting their newborn to die. The nurses interventions should be
based on which statement?
a. Tangible remembrances of the newborn (e.g., lock of hair, picture) prolong grief.
b. Photographs of newborns should not be taken after the death has occurred.
c. Funerals are not recommended because mother is still recovering from childbirth.
d. Parents should be encouraged to name their newborn if they have not done so already.
ANS: D
Naming the deceased newborn is an important step in the grieving process. It gives the parents a tangible
person for whom to grieve, which is a key component of the grieving process. Tangible remembrances and
photographs can make the newborn seem more real to the parents. Many NICUs will make bereavement
memory packets, which may include a lock of hair, handprint, footprints, bedside name card, and other
individualized objects. Families need to be informed of their options. The ritual of a funeral provides an
opportunity for the parents to be supported by relatives and friends.
PTS: 1 DIF: Cognitive Level: Analyze REF: 250
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
22. The nurse has been caring for a newborn who just died. The parents are present but say they are afraid to
hold the dead newborn. Which is the most appropriate nursing intervention?
a. Tell them there is nothing to fear.
b. Insist that they hold newborn one last time.
c. Respect their wishes and release body to morgue.
d. Keep newborns body available for a few hours in case they change their minds.
ANS: D
When the parents are hesitant about holding and touching their newborn, the nurse should keep the newborns
body for a few hours. Many parents change their minds after the initial shock of the newborns death. This will
provide the parents time to see and hold their newborn if they desire. Stating that there is nothing to fear
minimizes the parents feelings. The nurse should allow the family to parent their child as they wish in death, as
in life. Many parents change their minds; if possible, the nurse should wrap the newborn in blankets and keep
the newborns body on the unit for a few hours.
PTS: 1 DIF: Cognitive Level: Apply REF: 254
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
23. The nurse is planning care for a low-birth-weight newborn. Which is an appropriate nursing intervention to
promote adequate oxygenation?
a. Place in Trendelenburg position periodically.
b. Suction at least every 2 to 3 hours.
c. Maintain neutral thermal environment.
d. Hyperextend neck with nose pointing to ceiling.
ANS: C
A neutral thermal environment is one that permits the newborn to maintain a normal core temperature with
minimal oxygen consumption and caloric expenditure. The Trendelenburg position should be avoided. This
position can contribute to increased intracranial pressure (ICP) and reduced lung capacity from gravity pushing
organs against diaphragm. Suctioning should be done only as necessary. Routine suctioning may cause
bronchospasm, bradycardia due to vagal nerve stimulation, hypoxia, and increased ICP. Neck hyperextension
is avoided because it reduces diameter of trachea.
PTS: 1 DIF: Cognitive Level: Apply REF: 237
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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24. A preterm newborn has been receiving orogastric feedings of breast milk. The nurse initiates nipple
feedings, but the newborn tires easily and has weak sucking and swallowing reflexes. The most appropriate
nursing intervention is to:
a. encourage mother to breastfeed.
b. try nipple-feeding preterm newborn formula.
c. resume orogastric feedings of breast milk.
d. resume orogastric feedings of formula.
ANS: C
If a preterm newborn tires easily or has weak sucking when nipple feedings are initiated, the nurse should
resume orogastric feedings with the milk of mothers choice. When nipple feeding is unsuccessful, it is unlikely
that the newborn will be able to breastfeed. Breast milk should be continued as long as the mother desires.
PTS: 1 DIF: Cognitive Level: Apply REF: 242
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
25. The parents of a newborn who has just died decide they want to hold their deceased infant. The most
appropriate nursing intervention at this time is to:
a. explain gently that this is no longer possible.
b. encourage parents to accept the loss of their newborn.
c. offer to take a photograph of their newborn because they cannot hold newborn.
d. get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased
infant.
ANS: D
The parents should be allowed to hold their newborn in the hospital setting. The newborns body should be
retrieved and rewarmed in a radiant warmer. The nurse should provide a private place where the parents can
hold their child for a final time. A photograph is an excellent idea, but it does not replace the parents need to
hold the child.
PTS: 1 DIF: Cognitive Level: Apply REF: 254
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
26. Which statement best describes the clinical manifestations of the preterm newborn?
a. Head is proportionately small in relation to the body.
b. Sucking reflex is absent, weak, or ineffectual.
c. Thermostability is well established.
d. Extremities remain in attitude of flexion.
ANS: B
Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. The preterm newborns head
is proportionately larger than the body. Thermoregulation is poorly developed, and the preterm newborn needs
a neutral thermal environment to be provided. The preterm newborn may be listless and inactive compared
with the overall attitude of flexion and activity of a full-term newborn.
PTS: 1 DIF: Cognitive Level: Understand REF: 242
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
27. Physiologic jaundice in a newborn can be caused by:
a. fetal-maternal blood incompatibility.
b. destruction of red blood cells as a result of antibody reaction.
c. livers inability to bind bilirubin adequately for excretion.
d. immature kidneys inability to hydrolyze and excrete bilirubin.
ANS: C
Physiologic jaundice is caused by the immature hepatic function of the newborns liver coupled with the
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increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot
be excreted from the body. The fetal-maternal blood incompatibility and the associated red cell destruction by
antibodies are the causes of hemolytic disease of the newborn. The kidneys are not involved in the excretion of
bilirubin.
PTS: 1 DIF: Cognitive Level: Understand REF: 259
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
28. When should the nurse expect breastfeeding-associated jaundice to first appear in a normal newborn?
a. 0 to 12 hours
b. 12 to 24 hours
c. 2 to 4 days
d. 4 to 5 days
ANS: C
Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid
intake by the newborn before the mothers milk is well established. Fasting is associated with decreased hepatic
clearance of bilirubin; 0 to 24 hours is too soon. Jaundice within the first 24 hours is associated with hemolytic
disease of the newborn; 4 to 5 days is too late. Jaundice at this time may be due to breast-milk jaundice.
PTS: 1 DIF: Cognitive Level: Understand REF: 259
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
29. The newborn with severe jaundice is at risk for developing:
a. encephalopathy.
b. bullous impetigo.
c. respiratory distress.
d. blood incompatibility.
ANS: A
Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. A newborn with
severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Encephalopathy is a highly
infectious bacterial infection of the skin. It has no relation to severe jaundice and is the most likely
complication of severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.
PTS: 1 DIF: Cognitive Level: Understand REF: 260
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
30. Early clinical manifestations of bilirubin encephalopathy in the newborn include:
a. mental retardation.
b. absence of stooling.
c. lethargy or irritability.
d. increased or decreased temperature.
ANS: C
Clinical manifestations of bilirubin encephalopathy are those of nervous system depression or excitation.
Prodromal symptoms consist of decreased activity, lethargy, irritability, hypotonia, and seizures. Newborns
who survive may have evidence of mental retardation. Absence of stooling and increased/decreased
temperature are not manifestations of bilirubin encephalopathy.
PTS: 1 DIF: Cognitive Level: Understand REF: 261
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
31. A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice
in this newborn?
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a. Buttocks
b. Tip of nose and sclera
c. Sclera, conjunctiva, and oral mucosa
d. Palms of hands and soles of feet
ANS: C
Assessing for jaundice is part of the routine physical assessment in newborns. In dark-skinned newborns, the
sclera, conjunctiva, and oral mucosa are the best place to observe jaundice because of the lack of skin
pigmentation in these areas. The skin pigmentation in the buttocks, tip of nose and sclera, and palms of hands
and soles of feet can mask the appearance of jaundice.
PTS: 1 DIF: Cognitive Level: Apply REF: 262
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
32. A blood sample for measurement of bilirubin is required from a newborn receiving phototherapy. In what
environment should this blood sample be drawn?
a. While phototherapy lights are turned off
b. While newborn remains under phototherapy lights
c. When newborn is covered with a blanket
d. When newborn has been off phototherapy for 30 to 60 minutes
ANS: A
When blood is drawn, phototherapy lights are turned off, and the blood is transported in a covered tube to
avoid a false reading as a result of bilirubin destruction in the test tube. The lights will cause a degradation of
the bilirubin in the sample, resulting in a falsely lowered result. The newborn does not need to be covered with
a blanket. The phototherapy lights must be off. There is no reason to delay obtaining the blood sample. It can
be drawn as soon as the lights are turned off.
PTS: 1 DIF: Cognitive Level: Apply REF: 262
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
33. The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent
would indicate a need for further teaching?
a. I should change the babys position many times during the day.
b. I can dress the baby in lightweight clothing while under phototherapy.
c. I should be sure that the babys eyelids are closed before applying patches.
d. I can take the patches off the baby during feedings and other caregiving activities.
ANS: B
The baby should be placed nude under the lights. The newborn should be repositioned frequently to expose all
body surfaces to the lights. The newborns eyelids must be closed before the patches are applied because the
corneas may become excoriated if in contact with the dressing. The eye patches should be removed so the
newborn can have visual and sensory stimulation.
PTS: 1 DIF: Cognitive Level: Analyze REF: 261
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
34. The nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy. Which is an
appropriate nursing intervention for this newborn?
a. Apply lotion as prescribed to moisturize skin.
b. Maintain nothing-by-mouth (NPO) status to prevent nausea and vomiting.
c. Monitor temperature to prevent hypothermia or hyperthermia.
d. Keep eye patches on for at least 8 to 12 of every 24 hours.
ANS: C
Newborns who are receiving phototherapy are at risk for thermoregulation issues. The nurse must monitor the
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newborns temperature closely to rapidly detect either hypothermia or hyperthermia. Lotions are not used. They
may predispose the newborn to increased tanning or frying effect. Newborns receiving phototherapy require
additional fluid to compensate for increased fluid losses caused by the lights. The eye patches must be in place
whenever the child is under the phototherapy lights.
PTS: 1 DIF: Cognitive Level: Apply REF: 263
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
35. Hemolytic disease is suspected in a mothers second newborn. Which factor is important in understanding
how this could develop?
a. The mothers first child was Rh positive.
b. The mother is Rh positive.
c. Both parents have type O blood.
d. RhIG (RhoGAM) was given to the mother during her first pregnancy.
ANS: A
Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell (RBC) destruction.
The major causes of this are Rh and maternal-fetal ABO incompatibility. If an Rh-negative mother has
previously been exposed to Rh-positive blood through pregnancy or blood transfusion, antibodies to this blood
group antigen may develop so that she is isoimmunized. With further exposure to Rh, the maternal antibodies
will agglutinate with the red cells of the fetus who has the antigen and destroy the cells. Hemolytic disease is
also caused by ABO incompatibilities. Blood type is the important consideration. If both parents are type O
blood, ABO incompatibility would not be a possibility. The mother should have received Rho(D) immune
globulin to prevent antibody development after the first pregnancy.
PTS: 1 DIF: Cognitive Level: Analyze REF: 264
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
36. When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
a. At birth
b. During first 24 hours after birth
c. 24 to 48 hours after birth
d. 48 to 72 hours after birth
ANS: B
In hemolytic disease of the newborn, jaundice is usually evident within the first 24 hours of life. Newborns
with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor,
and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present; 24 to 72 hours is too
late for hemolytic disease of the newborn. Jaundice at these ages is most likely due to physiologic or earlyonset breastfeeding jaundice.
PTS: 1 DIF: Cognitive Level: Understand REF: 264
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
37. To prevent Rh isoimmunization, RhIG (RhoGAM) is administered to all:
a. Rh-negative women who deliver an Rh-positive newborn.
b. Rh-positive women who deliver an Rh-negative newborn.
c. Rh-negative newborns whose mothers are Rh positive.
d. Rh-positive fathers before conception of second newborn when first newborn was Rh positive.
ANS: A
Rh IG human gamma globulin concentrate of anti-D is administered to all unsensitized Rh-negative women
after delivery or abortion of an Rh-positive newborn or fetus. Administering RhIG to an individual who is Rh
positive will result in agglutination of red cells and hemolysis. It will not alter the persons genetic makeup. The
anti-D antibody contained in RhIG will have no effect on Rh-negative newborns because the D antibody is not
present.
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PTS: 1 DIF: Cognitive Level: Apply REF: 266
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
38. The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of
the newborn reveals slight respiratory distress and tachycardia. Which should the nurses first action be?
a. Notify practitioner.
b. Stop the transfusion.
c. Administer calcium gluconate.
d. Monitor vital signs electronically.
ANS: B
When signs of cardiac or respiratory problems occur, the procedure is stopped, and the newborns
cardiorespiratory status is allowed to stabilize. The practitioner is usually performing the exchange transfusion
with the nurses assistance. The procedure must be stopped so the newborn can stabilize. Respiratory distress
and tachycardia are signs of cardiorespiratory problems, not hypocalcemia. Calcium gluconate is not indicated.
The vital signs should be monitored electronically throughout the entire procedure.
PTS: 1 DIF: Cognitive Level: Apply REF: 267
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
39. Which is the primary treatment for hypoglycemia in newborns with feeding intolerance?
a. Oral glucose feedings
b. Intravenous (IV) infusion of glucose
c. Short-term insulin therapy
d. Feedings (formula or breast milk) at least every 2 hours
ANS: B
IV infusions of glucose are indicated when the glucose level is very low and when feedings are not tolerated.
Early feedings in the normoglycemic newborn are preventive. When the newborn is unable to tolerate feedings
or the blood glucose level has become extremely low, then IV infusions are indicated. Insulin administration
will further depress the blood glucose level. Feedings can be preventive. The child may not be able to tolerate
this frequency.
PTS: 1 DIF: Cognitive Level: Apply REF: 268
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
40. Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a
high-pitched cry?
a. Monitor blood pressure closely.
b. Obtain urine sample to detect glycosuria.
c. Obtain serum glucose and serum calcium levels.
d. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
ANS: C
These are signs and symptoms of hypocalcemia and hypoglycemia. A blood test is useful to determine the
treatment. Laboratory analysis for calcium and blood glucose should be the priority intervention. Monitoring
vital signs is important, but recognition of the possible hypocalcemia and hypoglycemia is imperative. A
finding of glycosuria would not facilitate the diagnosis of hypoglycemia. A determination must be made
between the hypocalcemia and hypoglycemia before treatment can be initiated.
PTS: 1 DIF: Cognitive Level: Apply REF: 268
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
41. The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of hypocalcemia.
Which intervention is the most appropriate during the acute phase?
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a. Allow newborn to sleep with pacifier to decrease stimuli.
b. Keep newborn awake to monitor central nervous system changes.
c. Encourage parents to hold and feed newborn to facilitate attachment during illness.
d. Awaken newborn periodically to assess level of consciousness.
ANS: A
For newborns with hypocalcemia, the nurse should manipulate the environment to reduce stimuli that might
precipitate a seizure or tremors. A quiet, nonstimulating environment should be maintained for the newborn
until calcium levels are normalized. Care should be provided without sudden jarring. Parents can be involved
in observations and care when the child is awake.
PTS: 1 DIF: Cognitive Level: Apply REF: 268
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
42. Which is the central factor responsible for respiratory distress syndrome?
a. Deficient surfactant production
b. Overproduction of surfactant
c. Overdeveloped alveoli
d. Absence of alveoli
ANS: A
The successful adaptation to extrauterine breathing requires numerous factors, which most term newborns
successfully accomplish. Preterm newborns with respiratory distress are not able to adjust. The most likely
central cause is the abnormal development of the surfactant system. The deficient production of surfactant
results in unequal inflation of alveoli on inspiration and the collapse of the alveoli on end expiration. The
number and state of development of the alveoli is not a central factor in respiratory distress syndrome. The
instability of the alveoli related to the lack of surfactant is the causative issue.
PTS: 1 DIF: Cognitive Level: Remember REF: 269
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
43. A preterm newborn of 36 weeks of gestation is admitted to the NICU. Approximately 2 hours after birth,
the newborn begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. Which is
important for the nurse to recognize?
a. This is a normal finding.
b. This is not significant unless cyanosis is present.
c. Improvement should occur within 24 hours.
d. Further evaluation is needed.
ANS: D
Difficulty breathing, with grunting, tachypnea, and nasal flaring are clinical manifestations of respiratory
distress syndrome and require further evaluation. This is not a normal finding and requires further evaluation.
Cyanosis may be present, but these are significant findings indicative of respiratory distress without cyanosis.
The childs condition will most likely worsen for approximately 48 hours without intervention. Improvement
may begin at 72 hours.
PTS: 1 DIF: Cognitive Level: Analyze REF: 274
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
44. The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of
respiratory distress syndrome. The nurse should recognize that, because of the mechanical ventilation, there is
an increased risk of:
a. alveolar rupture.
b. meconium aspiration.
c. transient tachypnea.
d. retractions and nasal flaring.
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ANS: A
Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured
alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Meconium aspiration is not associated
with mechanical ventilation. Tachypnea may be an indication of a pneumothorax, but it would not be transient.
Retractions and nasal flaring are indications of the use of accessory muscles when the newborn cannot obtain
sufficient oxygen. The use of mechanical ventilation bypasses the newborns need to use these muscles.
PTS: 1 DIF: Cognitive Level: Understand REF: 274
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
45. The nurse is caring for a newborn with respiratory distress syndrome. The newborn has an endotracheal
tube. Which statement describes nursing considerations related to suctioning?
a. Suctioning should not be carried out routinely.
b. Newborn should be in Trendelenburg position for suctioning.
c. Routine suctioning, usually every 15 minutes, is necessary.
d. Frequent suctioning is necessary to maintain patency of bronchi.
ANS: A
Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia, and increased
ICP. It should never be carried out routinely. The Trendelenburg position should be avoided. This position can
contribute to increased ICP and reduced lung capacity from gravity pushing organs against diaphragm. Routine
suctioning is avoided because of the potential complications of bronchospasm, bradycardia, hypoxia, and
increased ICP.
PTS: 1 DIF: Cognitive Level: Apply REF: 272
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
46. A premature newborn requires oxygen and mechanical ventilation. Which complications should the nurse
assess for?
a. Bronchopulmonary dysplasia, pneumothorax
b. Anemia, necrotizing enterocolitis
c. Cerebral palsy, persistent patent ductus
d. Congestive heart failure, cerebral edema
ANS: A
Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by mechanical
ventilation creates an increase in the number of ruptured alveoli and subsequent pneumothorax and
bronchopulmonary dysplasia. Anemia, necrotizing enterocolitis, cerebral palsy, persistent patent ductus,
congestive heart failure, and cerebral edema are complications not primarily due to oxygen therapy and
mechanical ventilation.
PTS: 1 DIF: Cognitive Level: Analyze REF: 274
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
47. Meconium aspiration syndrome is caused by:
a. hypoglycemia.
b. carbon dioxide retention.
c. bowel obstruction with meconium.
d. aspiration of meconium in utero or at birth.
ANS: D
Meconium aspiration syndrome is caused by the aspiration of amniotic fluid containing meconium into the
fetal or newborn trachea in utero or at first breath. Hypoglycemia and carbon dioxide retention are not related
to meconium aspiration. Bowel obstruction with meconium may be an indication of cystic fibrosis or
Hirschsprung disease, not meconium aspiration.
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PTS: 1 DIF: Cognitive Level: Understand REF: 274
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
48. Which is the most common cause of anemia in preterm newborns?
a. Frequent blood sampling
b. Respiratory distress syndrome
c. Meconium aspiration syndrome
d. Persistent pulmonary hypertension
ANS: A
The most common cause of anemia in preterm newborns is frequent blood-sample withdrawal and inadequate
erythropoiesis in acutely ill newborns. Microsamples should be used for blood tests, and the amount of blood
drawn should be monitored. Respiratory distress syndrome, meconium aspiration syndrome, and persistent
pulmonary hypertension are not causes of anemia. They may require frequent blood sampling, which will
contribute to the problem of decreased erythropoiesis and anemia.
PTS: 1 DIF: Cognitive Level: Understand REF: 264
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
49. A newborn is diagnosed with retinopathy of prematurity. The nurse should know that:
a. blindness cannot be prevented.
b. no treatment is currently available.
c. cryotherapy and laser therapy are effective treatments.
d. long-term administration of oxygen will be necessary.
ANS: C
Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular proliferation process that
causes the retinal damage. Blindness can be prevented with early recognition and treatment. Cryotherapy and
laser therapy can be used to stop the process. Surgical intervention can be used to repair a detached retina if
necessary. Long-term administration of oxygen is one of the causes. Oxygen should be used judiciously.
PTS: 1 DIF: Cognitive Level: Understand REF: 277
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
50. Several types of seizures can occur in the newborn. Which is characteristic of clonic seizures?
a. Apnea
b. Tremors
c. Rhythmic jerking movements
d. Extensions of all four limbs
ANS: C
Clonic seizures are characterized by slow rhythmic jerking movements that occur approximately 1 to 3 per
second. Apnea is a common manifestation of subtle seizures. Tremors are not characteristic of seizure activity.
They may be indicative of hypoglycemia or hypocalcemia. A clonic seizure would have extension and
contraction of the extremities, not just extension.
PTS: 1 DIF: Cognitive Level: Understand REF: 283
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
51. Newborns are highly susceptible to infection as a result of:
a. excessive levels of immunoglobulin A (IgA) and immunoglobulin M (IgM).
b. diminished nonspecific and specific immunity.
c. increased humoral immunity.
d. overwhelming anti-inflammatory response.
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ANS: B
Newborns have diminished inflammatory (nonspecific) and humoral (specific) immunity. They are unable to
mount a local inflammatory reaction at the portal of entry to signal infection, and the resulting symptoms are
vague and nonspecific, delaying diagnosis and treatment. Newborns have diminished or absent IgA and IgM.
Humoral and anti-inflammatory immune responses are diminished in newborns.
PTS: 1 DIF: Cognitive Level: Understand REF: 283
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
52. Which is most descriptive of the clinical manifestations observed in neonatal sepsis?
a. Seizures and sunken fontanels
b. Sudden hyperthermia and profuse sweating
c. Decreased urinary output and frequent stools
d. Nonspecific physical signs with hypothermia
ANS: D
The clinical manifestations of neonatal sepsis are usually characterized by the newborn generally not doing
well. Poor temperature control, usually with hypothermia, lethargy, poor feeding, pallor, cyanosis or mottling,
and jaundice, may be evident. Seizures and sunken fontanels are not manifestations of the sepsis. Severe
neurologic sequelae may occur in low-birth-weight children with sepsis. Hyperthermia is rare in neonatal
sepsis. Urinary output is not affected by sepsis.
PTS: 1 DIF: Cognitive Level: Understand REF: 284
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
53. The nurse is caring for a newborn whose mother is diabetic. Which clinical manifestations should the nurse
expect to see?
a. Hypoglycemic, large for gestational age
b. Hyperglycemic, large for gestational age
c. Hypoglycemic, small for gestational age
d. Hyperglycemic, small for gestational age
ANS: A
The clinical manifestations of a newborn born to a mother with diabetes include being large for gestational
age, being plump and full-faced, having abundant vernix caseosa, being listless and lethargic, and having
hypoglycemia. These manifestations appear a short time after birth. The newborn is hypoglycemic from
increased fetal production of insulin and large for gestational age.
PTS: 1 DIF: Cognitive Level: Understand REF: 286
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
54. The nurse is caring for a newborn who was born 24 hours ago to a mother who received no prenatal care.
The newborn is a poor feeder but sucks avidly on his hands. Clinical manifestations also include loose stools,
tachycardia, fever, projectile vomiting, sneezing, and generalized sweating. Which should the nurse suspect?
a. Seizure disorder
b. Narcotic withdrawal
c. Placental insufficiency
d. Meconium aspiration syndrome
ANS: B
Newborns exposed to drugs in utero usually show no untoward effects until 12 to 24 hours for heroin or much
longer for methadone. The newborn usually has nonspecific signs that may coexist with other conditions such
as hypocalcemia and hypoglycemia. In addition, these newborns may have loose stools, tachycardia, fever,
projectile vomiting, sneezing, and generalized sweating, which is uncommon in newborns. Loose stools,
tachycardia, fever, projectile vomiting, sneezing, and generalized sweating are manifestations not descriptive
of seizure activity. Placental insufficiency usually results in a child who is small for gestational age. Meconium
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aspiration syndrome usually has manifestations of respiratory distress.
PTS: 1 DIF: Cognitive Level: Apply REF: 288
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
55. Which should the nurse anticipate in the newborn whose mother used cocaine during pregnancy?
a. Seizures
b. Hyperglycemia
c. Cardiac and respiratory problems
d. Neurobehavioral depression or excitability
ANS: D
The nurse should anticipate neurobehavioral depression or excitability and implement care directed at the
newborns manifestations. Few or no neurologic sequelae appear in newborns born to mothers who use cocaine
during pregnancy. The newborn is usually a poor feeder, so hypoglycemia would be a more likely occurrence.
Cardiac and respiratory problems are usually not evident in these newborns.
PTS: 1 DIF: Cognitive Level: Understand REF: 290
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
56. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after
chromosome breakage?
a. Trisomy
b. Monosomy
c. Translocation
d. Nondisjunction
ANS: C
A translocation occurs when a part of a chromosome breaks off and attaches to another chromosome. When
this occurs in the germ cells, the translocation can be transmitted to the next generation. Trisomy is the
condition in which three of a specific chromosome are found rather than the usual two. Monosomy is the
condition in which one of a specific chromosome is noted rather than the usual two. The term is not used for
males when the normal complement of sex chromosomes (one X and one Y) is present. Nondisjunction is the
failure of a chromosome to separate during cell division. Of the resultant daughter cells, one will be trisomic
and one will be monosomic.
PTS: 1 DIF: Cognitive Level: Understand REF: 295
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
57. Trisomy 13, trisomy 18, and trisomy 21 have which in common?
a. Viability is rare.
b. They are considered deletion syndromes.
c. Diagnosis is difficult, time-consuming, and expensive.
d. Diagnosis can be made early, based on physical characteristics.
ANS: D
Each of these disorders, trisomy 13, 18, and 21, has unique physical characteristics. A presumptive diagnosis
can often be made soon after birth and later confirmed by chromosomal analysis. Children with trisomy 13 and
18 usually have short life expectancies. Trisomy 21 has a variable life expectancy, with 80% of individuals
living to age 30 years. Trisomy 13, trisomy 18, and trisomy 21 are not deletion syndromes.
PTS: 1 DIF: Cognitive Level: Understand REF: 295
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
58. Which is characteristic of newborns whose mothers smoked during pregnancy?
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a. Large for gestational age
b. Preterm, but size appropriate for gestational age
c. Growth retardation in weight only
d. Growth retardation in weight, length, and head circumference
ANS: D
Newborns born to mothers who smoke had growth failure in weight, length, and chest circumference when
compared with newborns of mothers who did not smoke. A dose-effect relation exists. Newborns have
significant growth failure, which is related to the number of cigarettes smoked.
PTS: 1 DIF: Cognitive Level: Understand REF: 297
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
59. Which is an important nursing consideration in preventing the complications of congenital hypothyroidism
(CH)?
a. Assess for family history of CH.
b. Assess mother for signs of hypothyroidism.
c. Be certain appropriate screening is done prenatally.
d. Be certain appropriate screening is done on newborn.
ANS: D
Early diagnosis and treatment are essential to prevent the complications of CH. Neonatal screening is
mandatory in all 50 United States and territories and is usually obtained in the first 24 to 48 hours of birth. A
number of different etiologies exist for CH; family history will identify a small percentage only. The screening
can be done postnatally on blood obtained via heel stick.
PTS: 1 DIF: Cognitive Level: Understand REF: 298
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
60. Phenylketonuria (PKU) is a genetic disease that results in the bodys inability to correctly metabolize:
a. glucose.
b. phenylalanine.
c. phenylketones.
d. thyroxine.
ANS: B
PKU is an inborn error of metabolism caused by a deficiency or absence of the enzyme needed to metabolize
the essential amino acid phenylalanine. Phenylalanine hydroxylase is missing in PKU. Individuals with this
disorder can metabolize glucose. Phenylketones are metabolites of phenylalanine, excreted in the urine.
Thyroxine is one of the principal hormones secreted by the thyroid gland.
PTS: 1 DIF: Cognitive Level: Understand REF: 299
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
61. The commonly used Guthrie blood test is performed on newborns to diagnose:
a. Down syndrome.
b. isoimmunization.
c. PKU.
d. congenital hypothyroidism (CH).
ANS: C
The Guthrie blood test is an assay commonly used to diagnosis PKU. The test should be performed after the
newborn has received postnatal feedings. Down syndrome is diagnosed through chromosomal analysis.
Isoimmunization is detected by analysis of blood for unexpected antibodies. CH is diagnosed by analysis of a
filter paper blood spot for thyroxine (T4).
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PTS: 1 DIF: Cognitive Level: Remember REF: 299
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
62. The screening test for PKU is most reliable if the blood sample is:
a. from cord blood.
b. taken 14 days after birth.
c. taken before oral feedings are initiated.
d. fresh blood from the heel.
ANS: D
Fresh heel-stick blood is the preferred source for the test. Fresh heel-stick blood, not cord blood, must be used.
The test must be performed soon after birth so that a low-phenylalanine diet can be instituted if required. The
newborn should ingest breast milk or formula before the test is performed.
PTS: 1 DIF: Cognitive Level: Understand REF: 299
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
63. Which is an important nursing consideration in the care of the newborn with PKU?
a. Suggest ways to make formula more palatable.
b. Teach proper administration of phenylalanine hydroxylase.
c. Encourage the breastfeeding mother to adhere to low-phenylalanine diet.
d. Give reassurance that dietary restrictions are a temporary inconvenience.
ANS: A
To achieve optimal metabolic control, a restricted phenylalanine diet will probably be required for virtually all
individuals with classic PKU throughout life. The nurse and nutritionist should work with families to make the
formula more palatable for the newborn. Phenylalanine hydroxylase is not effective because it cannot act
within the cell where phenylalanine is metabolized. Partial breastfeeding may be possible, but only with
extremely careful monitoring of the newborns blood levels. According to the latest research, lifelong dietary
restriction may be necessary.
PTS: 1 DIF: Cognitive Level: Apply REF: 300
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse needs to obtain blood for ongoing assessment of a high-risk newborns progress. Which tests
should the nurse monitor? (Select all that apply.)
a. Blood glucose
b. Complete blood count (CBC)
c. Calcium
d. Serum electrolytes
e. Neonatal prothrombin time (PTT)
ANS: A, C, D
The most common blood tests done on high-risk newborns are blood glucose, bilirubin, calcium, hematocrit,
serum electrolytes, and blood gases. Hematocrits rather than CBCs are performed. This will monitor the red
cell volume. Neonatal prothrombin time (PTT) is not a test.
PTS: 1 DIF: Cognitive Level: Understand REF: 237
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
2. Which are clinical manifestations of postmaturity in the newborn? (Select all that apply.)
a. Excessive lanugo
b. Increased subcutaneous fat
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c. Absence of scalp hair
d. Parchment-like skin
e. Minimal vernix caseosa
f. Long fingernails
ANS: D, E, F
In postmature newborns, the skin is often cracked, parchment-like, and desquamating; there is little to no
vernix caseosa; and fingernails are long. Lanugo is usually absent in postmature newborns. Subcutaneous fat is
usually depleted, giving the child a thin, elongated appearance. Scalp hair is usually abundant.
PTS: 1 DIF: Cognitive Level: Understand REF: 257
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate?
(Select all that apply.)
a. Avoid stimulation.
b. Decrease fluid intake.
c. Expose all the newborns skin.
d. Monitor skin temperature closely.
e. Reposition the newborn every 2 hours.
f. Cover the newborns eyes with eye shields or patches.
ANS: D, E, F
Several nursing interventions are instituted to protect the newborn during phototherapy. Temperature is closely
monitored to prevent hyperthermia or hypothermia. The newborn is repositioned every 2 hours to maximize
exposure to the phototherapy and to prevent skin breakdown. The infants eyes are shielded by an opaque mask
to prevent exposure to the light. The newborn is clothed in a diaper because a side effect of phototherapy
includes loose, greenish stools. Other side effects include increased metabolic rate; dehydration; electrolyte
disturbances, such as hypocalcemia; and priapism. Infants receiving phototherapy may require additional fluid
volume to compensate for insensible and intestinal fluid loss. The infant should receive adequate stimulation,
which includes feeding and touching.
PTS: 1 DIF: Cognitive Level: Apply REF: 263
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment
4. A nurse is planning care for a premature newborn. Which interventions should the nurse implement for skin
care? (Select all that apply.)
a. Use cleaning agents with neutral pH.
b. Rub skin during drying.
c. Use adhesive remover solvent when removing tape.
d. Avoid removing adhesives for at least 24 hours.
e. Consider pectin barriers beneath adhesives.
ANS: A, D, E
The skin care for a premature newborn should include use of pH-neutral cleanser or soaps no more than two or
three times a week. Adhesives should not be removed for at least 24 hours after application. Pectin barriers
should be used beneath adhesives to protect skin. Avoid rubbing skin during bathing or drying. Do not use
adhesive remover, solvents, or bonding agents. Adhesive removal can be facilitated using water, mineral oil, or
petrolatum.
PTS: 1 DIF: Cognitive Level: Apply REF: 245
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
5. A nurse is assessing a premature newborn for the possibility of necrotizing enterocolitis (NEC). Which
assessment findings should the nurse expect to find if NEC is confirmed? (Select all that apply.)
a. Minimal gastric residual
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b. Abdominal distention
c. Apnea
d. Urinary output at 2 ml/kg/hr
e. Unstable temperature
ANS: B, C, E
The nurse should observe for indications of early development of NEC by checking the appearance of the
abdomen for distention (measuring abdominal girth, measuring residual gastric contents before feedings, and
listening for bowel sounds) and performing all routine assessments for high-risk neonates. The premature
newborn may have apnea and unstable temperature if NEC is developing. The urinary output will be decreased
and will be below the expected 2 ml/kg/hr.
PTS: 1 DIF: Cognitive Level: Apply REF: 286
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
6. A nurse is admitting a premature newborn to the NICU. Which interventions should the nurse implement to
prevent retinopathy? (Select all that apply.)
a. Place on pulse oximetry.
b. Decrease exposure to bright, direct lighting.
c. Place on a cardiac monitor.
d. Cover eyes with an eye shield at night.
e. Use supplemental oxygen only when needed.
ANS: A, B, E
To prevent retinopathy, the nurse should provide preventive care by closely monitoring blood oxygen levels,
responding promptly to saturation alarms, and preventing fluctuations in blood oxygen levels. Pulse oximetry
is recommended to monitor the infants oxygenation status during resuscitation and to prevent excessive use of
oxygen in both term and preterm infants. Decrease exposure to bright, direct lighting; although exposure to
bright light has not been proven to contribute to retinopathy of prematurity, such exposure is undesirable from
a neurobehavioral developmental perspective. Use supplemental oxygen judiciously and monitor oxygen blood
levels carefully; prevent wide fluctuations in oxygen blood levels (hyperoxia and hypoxia). Placing the
newborn on a cardiac monitor will not prevent retinopathy. Covering the eyes with eye shields is not a
preventive measure for retinopathy.
PTS: 1 DIF: Cognitive Level: Apply REF: 277
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. A nurse is assessing a premature newborn. Which assessment findings are consistent with prematurity?
(Select all that apply.)
a. Abundant lanugo over the body
b. Ear cartilage soft and pliable
c. Flexed body posture
d. Deep creases on the sole of the foot
e. Skin is bright pink, smooth, and shiny.
ANS: A, B, E
The premature newborn has fine lanugo hair that is abundant over the body. The ear cartilage is soft and
pliable, and the soles and palms have minimal creases, resulting in a smooth appearance. The premature
newborns skin is bright pink (often translucent, depending on the degree of immaturity), smooth, and shiny,
with small blood vessels clearly visible underneath the thin epidermis. In contrast to full-term infants overall
attitude of flexion and continuous activity, preterm infants may be inactive and listless. The extremities
maintain an attitude of extension and remain in any position in which they are placed.
PTS: 1 DIF: Cognitive Level: Apply REF: 255
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
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8. A nurse is reviewing acid-base laboratory data on a newborn admitted to the NICU for meconium aspiration.
Which laboratory values should the nurse report to the physician? (Select all that apply.)
a. pH: 7.35
b. PCO2 : 49
c. HCO3-: 30
d. PaO2: 96
ANS: B, C
Normal values of pH for a newborn are:
Birth: 7.117.36
1 day: 7.297.45
Child: 7.357.45.
Normal values of PCO2 are:
Newborn: 2740 mm Hg
Infant: 2741 mm Hg
Girls: 3245 mm Hg
Boys: 3548 mm Hg.
Normal values for HCO3- are:
Infant: 2128 mEq/ml
Thereafter: 2226 mEq/ml.
The PaO2 is within normal limits for a newborn. Therefore, the nurse should report the PCO2 of 49 and the
HCO3- of 30.
PTS: 1 DIF: Cognitive Level: Analyze REF: 280
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity
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Chapter 09: Health Promotion of the Infant and Family
MULTIPLE CHOICE
1. A nurse is assessing a 12-month-old infant. Which statement best describes the infants physical development
a nurse should expect to find?
a. Anterior fontanel closes by age 6 to 10 months.
b. Binocularity is well established by age 8 months.
c. Birth weight doubles by age 5 months and triples by age 1 year.
d. Maternal iron stores persist during the first 12 months of life.
ANS: C
Growth is very rapid during the first year of life. The birth weight has approximately doubled by age 5 to 6
months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months. Binocularity is not
established until age 15 months. Maternal iron stores are usually depleted by age 6 months.
PTS: 1 DIF: Cognitive Level: Understand REF: 302
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
2. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect
the infant to now weigh approximately how many pounds?
a. 10
b. 15
c. 20
d. 25
ANS: B
Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds at birth would
weigh approximately 15 pounds; 10 pounds is too little. The infant would have gone from the 50th percentile
at birth to below the 5th percentile; 20 to 25 pounds is too much. The infant would have tripled the birth weight
at 6 months.
PTS: 1 DIF: Cognitive Level: Understand REF: 302
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is
closed. The nurse should interpret this as a(n):
a. normal finding.
b. finding requiring a referral.
c. abnormal finding.
d. normal finding, but requires rechecking in 1 month.
ANS: A
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No further intervention
is required.
PTS: 1 DIF: Cognitive Level: Apply REF: 302
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at
which age?
a. 6 to 8 weeks
b. 10 to 12 weeks
c. 4 to 6 months
d. 8 to 10 months
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ANS: A
The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks; 10 to 12 weeks, 4 to 6
months, and 8 to 10 months are too late. The posterior fontanel is usually closed by age 8 weeks.
PTS: 1 DIF: Cognitive Level: Remember REF: 302
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not
completely digested and can be seen in their infants stools. The nurses explanation of this is based on which
statement?
a. Child should not be given fibrous foods until digestive tract matures at age 4 years.
b. Child should not be given any solid foods until this digestive problem is resolved.
c. This is abnormal and requires further investigation.
d. This is normal because of the immaturity of digestive processes at this age.
ANS: D
The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are passed
incompletely broken down in the feces. An excess quantity of fiber predisposes the child to large, bulky stools.
This is normal for the child and is a normal part of the maturational process; no further investigation is
necessary.
PTS: 1 DIF: Cognitive Level: Apply REF: 302
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will
not voluntarily grasp it. The nurse should interpret this as:
a. normal development.
b. significant developmental lag.
c. slightly delayed development due to prematurity.
d. suggestive of a neurologic disorder such as cerebral palsy.
ANS: A
Holding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive grasping occurs
during the first 2 to 3 months and then gradually becomes voluntary. The infant is expected to be able to
perform this task by age 3 months. If the childs age is corrected because of being 2 weeks preterm, the child is
at the midpoint of the range for this developmental task and the behavior is age appropriate. No evidence of
neurologic dysfunction is present.
PTS: 1 DIF: Cognitive Level: Apply REF: 308
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. In terms of fine motor development, what should the infant of 7 months be able to do?
a. Transfer objects from one hand to the other and bang cubes on a table.
b. Use thumb and index finger in crude pincer grasp and release an object at will.
c. Hold a crayon between the fingers and make a mark on paper.
d. Release cubes into a cup and build a tower of two blocks.
ANS: A
By age 7 months, infants can transfer objects from one hand to the other, crossing the midline, and bang
objects on a hard surface. The crude pincer grasp is apparent at about age 9 months, and releasing an object at
will is seen around 8 months. The child can scribble spontaneously at age 15 months. At age 12 months, the
child can release cubes into a cup and build a small tower.
PTS: 1 DIF: Cognitive Level: Understand REF: 308
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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8. At what age can most infants sit steadily unsupported?
a. 4 months
b. 6 months
c. 8 months
d. 10 months
ANS: C
Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an
infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10
months, the infant can maneuver from a prone to a sitting position.
PTS: 1 DIF: Cognitive Level: Understand REF: 309
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face
down) while awake. The nurses response should be based on knowledge that this is:
a. unacceptable because of the risk of sudden infant death syndrome (SIDS).
b. unacceptable because it does not encourage achievement of developmental milestones.
c. acceptable to encourage fine motor development.
d. acceptable to encourage head control and turning over.
ANS: D
These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs
and then be placed on their abdomens when awake to enhance development of milestones such as head control.
The face-down position while awake and on the back for sleep are acceptable because they reduce risk of SIDS
and allow achievement of developmental milestones. These position changes encourage gross motor, not fine
motor, development.
PTS: 1 DIF: Cognitive Level: Analyze REF: 308
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. By which age should the nurse expect an infant to be able to pull to a standing position?
a. 6 months
b. 8 months
c. 11 to 12 months
d. 14 to 15 months
ANS: C
Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull
themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the
hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear
full weight on their legs. Any infant who cannot pull to a standing position by age 1 year should be referred for
further evaluation.
PTS: 1 DIF: Cognitive Level: Understand REF: 310
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. According to Piaget, the 6-month-old infant should be in which developmental stage?
a. Use of reflexes
b. Primary circular reactions
c. Secondary circular reactions
d. Coordination of secondary schemata
ANS: C
Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized
by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the
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noise of the rattle, not just for shaking. The use of reflexes is primarily during the first month of life. Primary
circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from
ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional
stage in which increasing motor skills enable greater exploration of the environment.
PTS: 1 DIF: Cognitive Level: Remember REF: 312
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior
indicates that an infant has developed object permanence?
a. Recognizes familiar face, such as mother
b. Recognizes familiar object, such as bottle
c. Actively searches for a hidden object
d. Secures objects by pulling on a string
ANS: C
During the first 6 months of life, infants believe that objects exist only as long as they can see them. When
infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an
infant knows an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to
respond differentially to the mother. They cry, smile, vocalize, and show distinct preference for the mother.
This preference is one of the stages that influences the attachment process but is too early for object
permanence. Recognizing familiar objects is an important transition for the infant, but it does not signal object
permanence. The ability to understand cause and effect is part of secondary schemata development.
PTS: 1 DIF: Cognitive Level: Understand REF: 312
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. A parent asks the nurse at what age do most infants begin to fear strangers? The nurse should give which
response?
a. 2 months
b. 4 months
c. 6 months
d. 12 months
ANS: C
Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the
infants ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning
to respond differentially to the mother. At age 4 months, the infant is beginning the process of separationindividuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late
and requires referral for evaluation if the child does not fear strangers at this age.
PTS: 1 DIF: Cognitive Level: Understand REF: 314
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. The nurse is interviewing the father of a 10-month-old infant. She is playing on the floor when she notices
an electric outlet and reaches up to touch it. Her father says no firmly and removes her from near the outlet.
The nurse should use this opportunity to teach the father that the infant:
a. is old enough to understand the word no.
b. is too young to understand the word no.
c. should already know that electric outlets are dangerous.
d. will learn safety issues better if she is spanked.
ANS: A
By age 10 months, children are able to associate meaning with words. The father is using both verbal and
physical cues to alert the child to dangerous situations. The child should be old enough to understand the word
no. The 10-month-old is too young to understand the purpose of an electric outlet. The father is using both
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verbal and physical cues to teach safety measures. Physical discipline should be avoided.
PTS: 1 DIF: Cognitive Level: Apply REF: 315
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A 4-month-old was born at 35 weeks of gestation. She seems to be developing normally, but her parents
are concerned because she is a more difficult baby than their other child, who was term. The nurse should
explain that:
a. infants temperaments are part of their unique characteristics.
b. infants become less difficult if they are not kept on scheduled feedings and structured routines.
c. the infants behavior is suggestive of failure to bond completely with her parents.
d. the infants difficult temperament is the result of painful experiences in the neonatal period.
ANS: A
Infant temperament has a strong biologic component. Together with interactions with the environment,
primarily the family, the biologic component contributes to the infants unique temperament. Children
perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to
demand feedings and frequent changes in routines. The infants temperament has been created by both biologic
and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to
the infants temperament.
PTS: 1 DIF: Cognitive Level: Understand REF: 315
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. Which information could be given to the parents of a 12-month-old child regarding appropriate play
activities?
a. Give large push-pull toys for kinetic stimulation.
b. Place cradle gym across crib to facilitate fine motor skills.
c. Provide child with finger-paints to enhance fine motor skills.
d. Provide stick horse to develop gross motor coordination.
ANS: A
The 12-month-old child is able to pull to standing and walk holding on or independently. Appropriate toys for
a child this age include large pull toys for kinesthetic stimulation. A cradle gym should not be placed across the
crib. Finger-paints are appropriate for older children. A 12-month-old child does not have the stability to use a
stick horse.
PTS: 1 DIF: Cognitive Level: Apply REF: 315
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
17. The nurse is discussing development and play activities with the parent of a 2-month-old.
Recommendations should include giving a first rattle at about which age?
a. 2 months
b. 4 months
c. 7 months
d. 9 months
ANS: B
It is recommended that a brightly colored toy or rattle be given to the child at age 4 months. Grasping has
begun as a deliberate act, and the infant grasps, holds, and begins shaking to hear a noise; 2 months is too
young. The infant still has primarily reflex grips; 7 to 9 months is too old for the first rattle. The child should
be given toys that provide for further exploration.
PTS: 1 DIF: Cognitive Level: Apply REF: 315
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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18. Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
a. Playing peek-a-boo
b. Playing pat-a-cake
c. Imitating animal sounds
d. Showing how to clap hands
ANS: A
Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill
for visual stimulation. Pat-a-cake and showing how to clap hands will help with kinetic stimulation. Imitating
animal sounds will help with auditory stimulation.
PTS: 1 DIF: Cognitive Level: Apply REF: 315
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
19. Which would be the best play activity for a 6-month-old infant to provide tactile stimulation?
a. Allow to splash in bath.
b. Give various colored blocks.
c. Play music box, tapes, or CDs.
d. Use infant swing or stroller.
ANS: A
The feel of the water while the infant is splashing will provide tactile stimulation. Various colored blocks
would provide visual stimulation for a 4- to 6-month-old infant. Music box, tapes, and CDs provide auditory
stimulation. Swings and strollers provide kinesthetic stimulation.
PTS: 1 DIF: Cognitive Level: Apply REF: 315
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?
a. 1 month
b. 2 months
c. 3 months
d. 4 months
ANS: B
At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. The
3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.
PTS: 1 DIF: Cognitive Level: Understand REF: 314
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
21. At what age does an infant start to recognize familiar faces and objects, such as a feeding bottle?
a. 1 month
b. 2 months
c. 3 months
d. 4 months
ANS: C
The child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants
watch and observe their surroundings. The 4-month-old infant is able to anticipate feeding after seeing the
bottle.
PTS: 1 DIF: Cognitive Level: Understand REF: 303
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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22. A parent asks the nurse when will my infant start to teethe? The nurse responds that the earliest age at
which an infant begins teething with eruption of lower central incisors is _____ months.
a. 4
b. 6
c. 8
d. 12
ANS: B
Teething usually begins at age 6 months with the eruption of the lower central incisors; 4 months is too early
for teething. By age 8 months, the infant has the upper and lower central incisors. At age 12 months, the infant
has six to eight deciduous teeth.
PTS: 1 DIF: Cognitive Level: Apply REF: 318
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
23. The nurse is guiding parents in selecting a daycare facility for their infant. Which is especially important to
consider when making the selection?
a. Health practices of facility
b. Structured learning environment
c. Socioeconomic status of children
d. Cultural similarities of children
ANS: A
Health practices should be most important. With the need for diaper changes and assistance with feeding,
young children are at increased risk when hand washing and other hygienic measures are not adhered to. A
structured learning environment is not suitable for this age child. The socioeconomic status of children should
have little effect on the choice of facility. Cultural similarities of children may be important to the families, but
the health care practices of the facility are more important.
PTS: 1 DIF: Cognitive Level: Understand REF: 316
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
24. Austin, age 6 months, has six teeth. The nurse should recognize that this is:
a. normal tooth eruption.
b. delayed tooth eruption.
c. unusual and dangerous.
d. earlier-than-normal tooth eruption.
ANS: D
Six months is earlier than expected. Most infants at age 6 months have two teeth. Although unusual, it is not
dangerous.
PTS: 1 DIF: Cognitive Level: Understand REF: 318
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
25. The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, hightop shoes. The nurse should explain that:
a. soft and flexible shoes are generally better.
b. high-top shoes are necessary for support.
c. inflexible shoes are necessary to prevent in-toeing and out-toeing.
d. this type of shoe will encourage the infant to walk sooner.
ANS: A
The main purpose of the shoe is protection. Soft, well-constructed, athletic-type shoes are best for infants and
children. High-top shoes are not necessary for support but may help to keep the childs foot in the shoe.
Inflexible shoes can delay walking and can aggravate in-toeing and out-toeing and impede development of the
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supportive foot muscles.
PTS: 1 DIF: Cognitive Level: Analyze REF: 339
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
26. The nurse should teach parents that which age is safe to give infants whole milk instead of commercial
infant formula?
a. 6 months
b. 9 months
c. 12 months
d. 18 months
ANS: C
The American Academy of Pediatrics does not recommend the use of cows milk for children younger than 12
months. At 6 and 9 months, the infant should be receiving commercial infant formula or breast milk. At age 18
months, milk and formula are supplemented with solid foods, water, and some fruit juices.
PTS: 1 DIF: Cognitive Level: Understand REF: 344
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
27. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should
recommend that the infant be given:
a. skim milk.
b. whole cows milk.
c. commercial iron-fortified formula.
d. commercial formula without iron.
ANS: C
For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If
breastfeeding has been discontinued, then iron-fortified commercial formula should be used. Cows milk should
not be used in children younger than 12 months. Maternal iron stores are almost depleted by this age; the ironfortified formula will help prevent the development of iron-deficiency anemia.
PTS: 1 DIF: Cognitive Level: Apply REF: 320
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
28. What is the best age for solid food to be introduced into the infants diet?
a. 2 to 3 months
b. 4 to 6 months
c. When birth weight has tripled
d. When tooth eruption has started
ANS: B
Physiologically and developmentally, the 4- to 6-month-old infant is in a transition period. The extrusion reflex
has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has
matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food.
Infants of this age will try to help during feeding; 2 to 3 months is too young. The extrusion reflex is strong,
and the child will push food out with the tongue. No research indicates that the addition of solid food to a
bottle has any benefit. Infant birth weight doubles at 1 year. Solid foods can be started earlier. Tooth eruption
can facilitate biting and chewing; most infant foods do not require this ability.
PTS: 1 DIF: Cognitive Level: Understand REF: 320
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
29. Which information should the nurse give a mother regarding the introduction of solid foods during
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infancy?
a. Solid foods should not be introduced until 8 to 10 months, when the extrusion reflex begins to disappear.
b. Foods should be introduced one at a time, at intervals of 4 to 7 days.
c. Solid foods can be mixed in a bottle to make the transition easier for the infant.
d. Fruits and vegetables should be introduced into the diet first.
ANS: B
One food item is introduced at intervals of 4 to 7 days to allow the identification of food allergies. Solid foods
can be introduced earlier. The extrusion reflex usually disappears by age 6 months. Mixing solid foods in a
bottle has no effect on the transition to solid food. Iron-fortified cereal should be the first solid food introduced
into the infants diet.
PTS: 1 DIF: Cognitive Level: Apply REF: 320
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
30. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able
to heat the babys formula faster. What should the nurse recommend?
a. Never heat a bottle in a microwave oven.
b. Heat only 10 ounces or more.
c. Always leave bottle top uncovered to allow heat to escape.
d. Shake bottle vigorously for at least 30 seconds after heating.
ANS: A
Bottles cannot be heated safely in microwave ovens even if safe guidelines are followed and regardless of the
amount to be heated due to uneven heating and possible burns.
PTS: 1 DIF: Cognitive Level: Apply REF: 338
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
31. Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this.
The nurses response should be based on which statement?
a. Children should not sleep with their parents.
b. Separation from parents should be completed by this age.
c. Daytime attention should be increased.
d. This is a common and accepted practice, especially in some cultural groups.
ANS: D
Co-sleeping, or sharing the family bed, in which the parents allow the children to sleep with them, is a common
and accepted practice in many cultures. Parents should evaluate the options available and avoid conditions that
place the infant at risk. Population-based studies are currently under way; no evidence at this time supports or
condemns the practice for safety reasons. Co-sleeping is a cultural practice. One year is the age at which
children are just beginning to individuate. Increased daytime activity may help decrease sleep problems in
general, but co-sleeping is a culturally determined phenomenon.
PTS: 1 DIF: Cognitive Level: Understand REF: 314
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
32. The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed.
The nurses best response should be:
a. She needs to begin taking them now.
b. They are not needed if you drink fluoridated water.
c. She may need to begin taking them at age 4 months.
d. She can have infant cereal mixed with fluoridated water instead of supplements.
ANS: C
Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 4 months
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if the child is not drinking adequate amounts of fluoridated water. The amount of water that is ingested and the
amount of fluoride in the water are taken into account when supplementation is being considered.
PTS: 1 DIF: Cognitive Level: Apply REF: 319
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
33. A parent asks the nurse whether her infant is susceptible to pertussis. The nurses response should be based
on which statement concerning susceptibility to pertussis?
a. Neonates will be immune the first few months.
b. If the mother has had the disease, the infant will receive passive immunity.
c. Children younger than 1 year seldom contract this disease.
d. Most children are highly susceptible from birth.
ANS: D
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6
weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years,
when the risks of the vaccine become greater than those of pertussis. The infant is highly susceptible to
pertussis, which can be a life-threatening illness in this age group.
PTS: 1 DIF: Cognitive Level: Apply REF: 329
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
34. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated
with injections. The nurse should explain that:
a. this cannot be prevented.
b. infants do not feel pain as adults do.
c. this is not a good reason for refusing immunizations.
d. a topical anesthetic, EMLA, can be applied before injections are given.
ANS: D
Several topical anesthetic agents can be used to minimize the discomfort associated with immunization
injections. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain
associated with many procedures can be prevented and minimized by using the principles of atraumatic care.
With preparation, the injection site can be properly anesthetized to decrease the amount of pain felt by the
infant. Infants have the neural pathways to feel pain. Numerous research studies have indicated that infants
perceive and react to pain in the same manner as do children and adults. The mother should be allowed to
discuss her concerns and the alternatives available. This is part of the informed consent process.
PTS: 1 DIF: Cognitive Level: Apply REF: 333
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
35. The parents of a 12-month-old child ask the nurse whether the child can eat hot dogs. The nurses reply
should be based on which statement?
a. Child is too young to digest hot dogs.
b. Child is too young to eat hot dogs safely.
c. Hot dogs must be sliced into sections to prevent aspiration.
d. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
ANS: D
Hot dogs are of a consistency, diameter, and round shape that may cause complete obstruction of the childs
airway. If given to young children, the hot dog should be cut into small irregular pieces rather than served
whole or in slices. The childs digestive system is mature enough to digest hot dogs. To eat the hot dog safely,
the child should be sitting down, and the hot dog should be appropriately cut.
PTS: 1 DIF: Cognitive Level: Apply REF: 340
TOP: Integrated Process: Teaching/Learning
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MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control (Injury
Prevention)
36. The clinic is lending a federally approved car seat to an infants family. The nurse should explain that the
safest place to put the car seat is:
a. front facing in back seat.
b. rear facing in back seat.
c. front facing in front seat with airbag on passenger side.
d. rear facing in front seat if an air bag is on the passenger side.
ANS: B
The rear-facing car seat provides the best protection for an infants disproportionately heavy head and weak
neck. The middle of the back seat is the safest position for the child. The infant must be rear facing to protect
the head and neck in the event of an accident. Severe injuries and deaths in children have occurred from air
bags deploying on impact in the front passenger seat.
PTS: 1 DIF: Cognitive Level: Understand REF: 337
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
37. Which figure depicts an expected developmental milestone for a 7-month-old infant?
a. c.
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Chapter 10: Health Problems of Infants
MULTIPLE CHOICE
1. 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: 331
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. Which vitamin is recommended for all women of childbearing age to reduce the risk of neural tube defects
such as spina bifida?
a. 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: 331
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
3. A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the nurse expect?
a. 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 electrolyte imbalance. Anemia and protein deficiency is a
common finding in malnourished children with kwashiorkor.
PTS: 1 DIF: Cognitive Level: Understand REF: 333
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. 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
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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 fatsoluble 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: 333
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
5. 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: 331
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
6. A nurse is preparing to administer an oral iron supplement to a hospitalized infant. Which should not be
given simultaneously with the iron supplement?
a. Milk
b. Multivitamin
c. Fruit juice
d. Meat, fish, poultry
ANS: A
Many foods interfere with iron absorption and should be avoided when the iron is consumed. These foods
include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables.
Multivitamins may contain iron; no contraindication exists to taking the two together. Vitamin 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: 332
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse counsels the
parents that which vitamin can cause a toxic reaction at a low dose?
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 331
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
8. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child. Which is
most likely lacking in their particular diet?
a. Fat
b. Protein
c. Vitamins C and A
d. Complete protein
ANS: D
The vegetarian diet can be extremely healthy, meeting the overall nutrition objectives for Healthy People.
Parents should be taught about food preparation to ensure that complete proteins are available for growth.
When parents use a strict vegetarian diet, likelihood exists of inadequate protein for growth and calories for
energy. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available.
Foods must be combined to provide complete proteins for growth.
PTS: 1 DIF: Cognitive Level: Understand REF: 332
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
9. 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
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: 333
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
10. Although infants may be allergic to a variety of foods, the most common allergens are:
a. fruit and eggs.
b. fruit, vegetables, and wheat.
c. 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.
PTS: 1 DIF: Cognitive Level: Remember REF: 334
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
11. Cows milk allergy (CMA) is diagnosed in a 6-month-old infant. Which should the nurse recommend as a
substitute formula?
a. Nutramigen
b. Goats milk
c. Similac
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d. Enfamil
ANS: A
Treatment of CMA is elimination of cows milkbased formula and all other dairy products. For infants fed cows
milk formula, this primarily involves changing the formula to a casein hydrolysate milk formula (Pregestimil,
Nutramigen, or Alimentum). Goats milk (raw) is not an acceptable substitute because it cross-reacts with cows
milk protein, is deficient in folic acid, has a high sodium and protein content, and is unsuitable as the only
source of calories. Cows milk protein is contained in both Enfamil and Similac.
PTS: 1 DIF: Cognitive Level: Apply REF: 336
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
12. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the
teaching plan?
a. Avoid use of pacifiers.
b. Eliminate all second-hand smoke contact.
c. Lay infant flat after feeding.
d. Avoid swaddling the infant.
ANS: B
To prevent and treat colic, teach parents that if household members smoke, avoid smoking near infant;
preferably confine smoking activity to outside of home. A pacifier can be introduced for added sucking. The
infant should be swaddled tightly with a soft, stretchy blanket and placed in an upright seat after feedings.
PTS: 1 DIF: Cognitive Level: Apply REF: 343
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
13. A parent of an infant with colic tells the nurse, All this baby does is scream at me; it is a constant worry.
The nurses best action is:
a. encourage parent to verbalize feelings.
b. encourage parent not to worry so much.
c. assess parent for other signs of inadequate parenting.
d. reassure parent that colic rarely lasts past age 9 months.
ANS: A
Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and
worry. The nurse should allow the parent to put these feelings into words. An empathic, gentle, and reassuring
attitude, in addition to suggestions about remedies, will help alleviate the parents anxieties. The nurse should
reassure the parent that he or she is not doing anything wrong. Colic is multifactorial. The infant with colic is
experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling
the parent that it will eventually go away does not help him or her through the current situation.
PTS: 1 DIF: Cognitive Level: Apply REF: 343
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
14. Parent guidelines for relieving colic in an infant include:
a. avoiding touching abdomen.
b. avoiding using a pacifier.
c. changing infants position frequently.
d. placing infant where family cannot hear the crying.
ANS: C
Changing the infants position frequently may be beneficial. The parent can walk holding the child face down
and with the childs chest across the parents arm. The parents hand can support the childs abdomen, applying
gentle pressure. Gently massaging the abdomen is effective in some children. Pacifiers can be used for meeting
additional sucking needs. The child should not be placed where monitoring cannot be done. The child can be
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placed in the crib and allowed to cry. Periodically, the child should be picked up and comforted.
PTS: 1 DIF: Cognitive Level: Apply REF: 343
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
15. Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of
calories include:
a. avoidance of eye contact.
b. an associated malabsorption defect.
c. weight that falls below the 15th percentile.
d. normal achievement of developmental landmarks.
ANS: A
One of the clinical manifestations of nonorganic failure to thrive is the childs avoidance of eye contact with the
health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but
not height) below the 5th percentile is indicative of failure to thrive. Developmental delays, including social,
motor, adaptive, and language, exist.
PTS: 1 DIF: Cognitive Level: Understand REF: 338
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
16. Which is an important nursing consideration when caring for an infant with failure to thrive?
a. Establish a structured routine and follow it consistently.
b. Maintain a nondistracting environment by not speaking to child during feeding.
c. Place child in an infant seat during feedings to prevent overstimulation.
d. Limit sensory stimulation and play activities to alleviate fatigue.
ANS: A
The infant with failure to thrive should have a structured routine that is followed consistently. Disruptions in
other activities of daily living can have a great impact on feeding behaviors. Bathing, sleeping, dressing,
playing, and feeding are structured. The nurse should talk to the child by giving directions about eating. This
will help the child maintain focus. Young children should be held while being fed, and older children can sit at
a feeding table. The child should be fed in the same manner at each meal. The child can engage in sensory and
play activities at times other than mealtime.
PTS: 1 DIF: Cognitive Level: Apply REF: 338
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
17. An important nursing responsibility when dealing with a family experiencing the loss of an infant from
sudden infant death syndrome (SIDS) is to:
a. explain how SIDS could have been predicted and prevented.
b. interview parents in depth concerning the circumstances surrounding the childs death.
c. discourage parents from making a last visit with the infant.
d. make a follow-up home visit to parents as soon as possible after the childs death.
ANS: D
A competent, qualified professional should visit the family at home as soon as possible after the death and
provide the family with printed information about SIDS. An explanation of how SIDS could have been
predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause
will only increase parental guilt. The parents should be asked only factual questions to determine the cause of
death. Parents should be allowed and encouraged to make a last visit with their child.
PTS: 1 DIF: Cognitive Level: Apply REF: 348
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
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18. Which is an appropriate action when an infant becomes apneic?
a. Shake vigorously.
b. Roll head side to side.
c. Hold by feet upside down with head supported.
d. Gently stimulate trunk by patting or rubbing.
ANS: D
If the infant is apneic, the infants trunk should be gently stimulated by patting or rubbing. If the infant is prone,
turn onto the back. The infant should not be shaken vigorously, the head rolled side to side, or held by the feet
upside down with the head supported. These can cause injury.
PTS: 1 DIF: Cognitive Level: Apply REF: 349
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
19. To prevent plagiocephaly, the nurse should teach parents to:
a. place infant prone for 30 to 60 minutes per day.
b. buy a soft mattress.
c. allow infant to nap in the car safety seat.
d. have infant sleep with the parents.
ANS: A
Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or
tummy time for approximately 30 to 60 minutes per day when the infant is awake. Soft mattresses or sleeping
with parents (co-sleeping) are not recommended because they put the infant at a higher risk for a sudden infant
death incident. To prevent plagiocephaly, prolonged placement in car safety seats should be avoided.
PTS: 1 DIF: Cognitive Level: Apply REF: 343
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
20. An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency
department. Which is an appropriate question to ask the parents?
a. Did you hear the infant cry out?
b. Why didnt you check on the infant earlier?
c. What time did you find the infant?
d. Was the head buried in a blanket?
ANS: C
During a SIDS incident, if the infant is not pronounced dead at the scene, he or she may be transported to the
emergency department to be pronounced dead by a physician. While they are in the emergency department, the
parents are asked only factual questions, such as when they found the infant, how he or she looked, and whom
they called for help. The nurse avoids any remarks that may suggest responsibility, such as Why didnt you go
in earlier? Didnt you hear the infant cry out? Was the head buried in a blanket?
PTS: 1 DIF: Cognitive Level: Apply REF: 347
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
21. An infant experienced an apparent life-threatening event (ALTE) and is being placed on home apnea
monitoring. Parents have understood the instructions for use of a home apnea monitor when they state:
a. We can adjust the monitor to eliminate false alarms.
b. We should sleep in the same bed as our monitored infant.
c. We will check the monitor several times a day to be sure the alarm is working.
d. We will place the monitor in the crib with our infant.
ANS: C
The parents should check the monitor several times a day to be sure the alarm is working and that it can be
heard from room to room. The parents should not adjust the monitor to eliminate false alarms. Adjustments
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could compromise the monitors effectiveness. The monitor should be placed on a firm surface away from the
crib and drapes. The parents should not sleep in the same bed as the monitored infant.
PTS: 1 DIF: Cognitive Level: Apply REF: 349
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
22. What should the nurse suggest to the parents of an infant who has a prolonged need for middle-of-the-night
feedings?
a. Decrease daytime feedings.
b. Allow child to go to sleep with a bottle.
c. Offer last feeding as late as possible at night.
d. Put infant to bed after asleep from rocking.
ANS: C
To manage an infant who has a prolonged need for middle-of-the-night feedings parents should be taught to
offer last feeding as late as possible at night. Parent should increase daytime feeding intervals to 4 hours or
more (may need to be done gradually), offer no bottles in bed, put to bed awake and when child is crying,
check at progressively longer intervals each night; reassure child but do not hold, rock, take to parents bed, or
give bottle or pacifier.
PTS: 1 DIF: Cognitive Level: Apply REF: 341
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
23. A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention should the
nurse implement?
a. Provide stimulation during feeding.
b. Avoid being persistent during feeding time.
c. Limit feeding time to 10 minutes.
d. Maintain a face-to-face posture with the infant during feeding.
ANS: D
The nurse preparing to feed an infant with failure to thrive should maintain a face-to-face posture with the
infant when possible. Encourage eye contact and remain with the infant throughout the meal. Stimulation is not
recommended; a quiet, unstimulating atmosphere should be maintained. Persistence during feeding may need
to be implemented. Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish
negative behavior. Although forced feeding is avoided, strictly encouraged feeding is essential. The length of
the feeding should be established (usually 30 minutes); limiting the feeding to 10 minutes would make the
infant feel rushed.
PTS: 1 DIF: Cognitive Level: Apply REF: 340
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been noted of
which of the following pediatric disorders? (Select all that apply.)
a. SIDS
b. Torticollis
c. Failure to thrive
d. Apnea of infancy
e. Plagiocephaly
ANS: B, E
Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull. If that side
becomes misshapen, facial asymmetry may result. The sternocleidomastoid muscle may tighten on the affected
side, causing torticollis. SIDS has decreased by more than 40% with the introduction of the Back to Sleep
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campaign. Apnea of infancy and failure to thrive are unrelated to the Back to Sleep campaign.
PTS: 1 DIF: Cognitive Level: Understand REF: 338
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death
syndrome (SIDS). Which risk factors should the nurse include as increasing an infants risk of a sudden infant
death syndrome incident? (Select all that apply.)
a. Breastfeeding
b. Low Apgar scores
c. Male sex
d. Birth weight in the 50th or higher percentile
e. Recent viral illness
ANS: B, C, E
Certain groups of infants are at increased risk for SIDS: low birth weight, low Apgar scores, recent viral
illness, and male sex. Breastfed infants and infants of average or above average weight are not at higher risk
for SIDS.
PTS: 1 DIF: Cognitive Level: Understand REF: 347
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. An infant has been diagnosed with cows milk allergy. What are the clinical manifestations the nurse expects
to assess? (Select all that apply.)
a. Pink mucous membranes
b. Vomiting
c. Rhinitis
d. Abdominal pain
e. Moist skin
ANS: B, C, D
An infant with cows milk allergy will possibly have vomiting, rhinitis, and abdominal pain. The mucous
membranes may be pale due to anemia from blood lost in the GI tract, and the skin will be itchy with the
possibility of atopic dermatitis.
PTS: 1 DIF: Cognitive Level: Understand REF: 337
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. Which interventions should the nurse implement when caring for a family of a sudden infant death
syndrome (SIDS) infant? (Select all that apply.)
a. Allow parents to say goodbye to their infant.
b. Once parents leave the hospital, no further follow-up is required.
c. Arrange for someone to take the parents home from the hospital.
d. Avoid requesting an autopsy of the deceased infant.
e. Conduct a debriefing session with the parents before they leave the hospital.
ANS: A, C, E
An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say
good-bye to their infant. These are the parents last moments with their infant, and they should be as quiet,
meaningful, peaceful, and undisturbed as possible. Because the parents leave the hospital without their infant,
it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session
may help health care workers who dealt with the family and deceased infant to cope with emotions that are
often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible
misconceptions regarding the death. When the parents return home, a competent, qualified professional should
visit them after the death as soon as possible.
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PTS: 1 DIF: Cognitive Level: Understand REF: 348
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
SHORT ANSWER
1. An infant is having an anaphylactic reaction, and the nurse is preparing to administer epinephrine 0.001
mg/kg. The child weighs 22 pounds. What is the epinephrine dose the nurse should administer? (Record your
answer using two decimal places.)
ANS:
0.01
Convert the 22 pounds to kilograms by dividing 22 by 2.2 = 10. Multiply the 10 by 0.001 mg of epinephrine =
0.01 mg as the dose to be given.
PTS: 1 DIF: Cognitive Level: Apply REF: 336
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
ESSAY
1. A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after
ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of
the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a,
b, c, d).
a. Call Jasons parents and notify them of the situation.
b. Call Jasons family practitioner to obtain further orders for medication.
c. Promptly administer an intramuscular dose of epinephrine.
d. Call 911 and wait for the emergency response personnel to arrive.
ANS:
c, d, b, a
The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress,
wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be
contacted for further orders and, last, the parents notified of the situation.
PTS: 1 DIF: Cognitive Level: Apply REF: 335
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
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Chapter 11: Health Promotion of the Toddler and Family
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: 355
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. The psychosocial developmental tasks of toddlerhood include which characteristic?
a. Development of a conscience
b. Recognition of sex differences
c. Ability to get along with age-mates
d. Ability to delay gratification
ANS: D
If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence,
and autonomy. One of the tasks that the toddler is concerned with is the ability to delay gratification.
Development of a conscience occurs during the preschool years. The recognition of sex differences occurs
during the preschool years. The ability to get along with age-mates develops during the preschool and schoolage years.
PTS: 1 DIF: Cognitive Level: Understand REF: 356
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: 356
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.
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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: 355
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 356
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: 357
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 357
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 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: 361
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: 358
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 18-month-old child has a vocabulary of 10 or more words. At this age, the
child does not use the one-word sentences that are characteristic of the 1-year-old child. The child has a limited
vocabulary of single words that are comprehensible.
PTS: 1 DIF: Cognitive Level: Understand REF: 360
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.
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c. Watching older siblings use the toilet confuses the child.
d. Children must be forced to sit on the toilet when first learning.
ANS: B
Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child
must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on
rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings
provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty
chair or toilet in a nonthreatening manner.
PTS: 1 DIF: Cognitive Level: Understand REF: 361
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: 355
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: 356
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: 360
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: 365
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: 365
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 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: 366
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.
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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: 366
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: 365
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
20. Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table with the family
briefly, and wants snacks all the time. Which intervention should the nurse recommend?
a. Give her nutritious snacks.
b. Offer rewards for eating at mealtimes.
c. Avoid snacks so she is hungry at mealtimes.
d. Explain to her in a firm manner what is expected of her.
ANS: A
Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated
with the slower growth rate. Parents should help the child develop healthy eating habits. The toddler is often
unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with
developing healthy eating habits, food should be not be used as positive or negative reinforcement for
behavior. The child may develop habits of overeating or eat nonnutritious foods in response.
PTS: 1 DIF: Cognitive Level: Apply REF: 366
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
21. A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go
to a restaurant. 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
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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: 367
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: 367
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
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: 370
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: 371
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
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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: 372
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. 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: 372
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
27. The nurse recommends to parents that peanuts are not a good snack food for toddlers. 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: 367
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
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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: 378
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.
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: 377
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: 379
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: 358
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
32. Parents need further teaching about the use of car safety seats if they make which statement?
a. Even if our toddler helps buckle the straps, we will double-check the fastenings.
b. We 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: 376
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: 363
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 373
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 362
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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Chapter 12: Health Promotion of the Preschooler and Family
MULTIPLE CHOICE
1. Which should the nurse expect of a healthy 3-year-old child?
a. Jump rope.
b. Ride a two-wheel bicycle.
c. Skip on alternate feet.
d. Balance on one foot for a few seconds.
ANS: D
Three-year-olds are able to accomplish this gross motor skill. Jumping rope, riding a two-wheel bicycle, and
skipping on alternate feet are gross motor skills of 5-year-olds.
PTS: 1 DIF: Cognitive Level: Understand REF: 381
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 5-year-olds.
PTS: 1 DIF: Cognitive Level: Understand REF: 381
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.
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: 382
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.
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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: 382
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: 382
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
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: 382
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: 383
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?
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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: 384
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. 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: 385
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: 383
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: 383
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?
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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-yearold. Hammering a nail and making change out of a quarter are fine motor and cognitive tasks of an 8- to 9year-old.
PTS: 1 DIF: Cognitive Level: Understand REF: 387
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
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: 385
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: 383
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 391
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
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: 389
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: 390
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: 390
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 age because preschoolers are becoming more
independent. Punishment may make children scared of trying new things. Limitation of physical activities is
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not appropriate.
PTS: 1 DIF: Cognitive Level: Understand REF: 392
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: 389
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). Low-fat milk may be
substituted, so the quantity of milk may remain the same while limiting fat intake overall. Parents should be
educated regarding non-nutritious fruit drinks, which usually contain less than 10% fruit juice yet are often
advertised as healthy and nutritious; sugar content is dramatically increased and often precludes an adequate
intake of milk by the child. In young children, intake of carbonated beverages that are acidic or that contain
high amounts of sugar is also known to contribute to dental caries. Low fat milk should be substituted for
whole milk if the child is slightly overweight.
PTS: 1 DIF: Cognitive Level: Apply REF: 390
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. In terms of language and cognitive development, a 4-year-old child would be expected to have which traits?
(Select all that apply.)
a. 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
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think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. Fiveyear-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: 386
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: 384
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 390
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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Chapter 13: Health Problems of Toddlers and Preschoolers
MULTIPLE CHOICE
1. Which is described as the time interval between infection or exposure to disease and appearance of initial
symptoms?
a.
Incubation period
b.
Prodromal period
c.
Desquamation period
d.
Period of communicability
ANS: A
The incubation period is the interval between infection or exposure and appearance of symptoms. The
prodromal period is the interval between the time when early manifestations of disease appear and the overt
clinical syndrome is evident. Desquamation refers to the shedding of skin. The period of communicability is
the time or times during which an infectious agent may be transferred directly or indirectly from an infected
person to another person.
PTS: 1 DIF: Cognitive Level: Remember REF: 395
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
2. Airborne isolation is required for a child who is hospitalized with:
a.
mumps.
b.
chickenpox.
c.
exanthema subitum (roseola).
d.
erythema infectiosum (fifth disease).
ANS: B
Chickenpox is communicable through direct contact, droplet spread, and contaminated objects. Mumps is
transmitted from direct contact with saliva of infected person and is most communicable before onset of
swelling. The transmission and source of the viral infection exanthema subitum (roseola) is unknown.
Erythema infectiosum (fifth disease) is communicable before onset of symptoms.
PTS: 1 DIF: Cognitive Level: Understand REF: 395
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Safe and Effective Care Environment
3. Acyclovir (Zovirax) is given to children with chickenpox to:
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a.
minimize scarring.
b.
decrease the number of lesions.
c.
prevent aplastic anemia.
d.
prevent spread of the disease.
176
ANS: B
Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching, lethargy, and
anorexia. Treating pruritus and discouraging itching minimizes scarring. Aplastic anemia is not a complication
of chickenpox. Strict isolation until vesicles are dried prevents spread of disease.
PTS: 1 DIF: Cognitive Level: Understand REF: 400
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
4. The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she
cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will
shorten the course of the illness. Which is the most appropriate nursing intervention?
a. Reassure the parent that it is not necessary to stay home with the child.
b.Explain that no medication will shorten the course of the illness.
c. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
d.Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
ANS: C
Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and decreasing
itching, lethargy, and anorexia. It is important the parent stay with the child to monitor fever. Acyclovir lessens
the severity of chickenpox. VariZIG is given only to high-risk children.
PTS: 1 DIF: Cognitive Level: Apply REF: 400
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Physiologic Integrity
5. Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
a.
Acyclovir (Zovirax)
b.
Varicella globulin
c.
Diphenhydramine hydrochloride (Benadryl)
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d.
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VCZ immune globulin (VariZIG)
ANS: D
VariZIG is given to high-risk children to prevent the development of chickenpox. Acyclovir decreases the
severity, not the development, of chickenpox. Varicella globulin is not effective because it is not the immune
globulin. Diphenhydramine may help pruritus but not the actual chickenpox.
PTS: 1 DIF: Cognitive Level: Understand REF: 400
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
6. Vitamin A supplementation may be recommended for the young child who has which disease?
a.
Mumps
b.
Rubella
c.
Measles (rubeola)
d.
Erythema infectiosum
ANS: C
Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated with analgesics for
pain and antipyretics for fever. Rubella is treated similarly to mumps. Erythema infectiosum is treated similarly
to mumps and rubella.
PTS: 1 DIF: Cognitive Level: Understand REF: 402
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
7. A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents
know that the child is considered to be no longer contagious when which occurs?
a.
When fever is absent
b.
When lesions are crusted
c.
24 hours after lesions erupt
d.
8 days after onset of illness
ANS: B
When the lesions are crusted, the chickenpox is no longer contagious. This may be a week after onset of
disease. Chickenpox is still contagious when child has fever. Children are contagious after lesions erupt. If
lesions are crusted at 8 days, the child is no longer contagious.
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PTS: 1 DIF: Cognitive Level: Apply REF: 395
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Physiologic Integrity
8. A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik
spots present?
a.
Rubella
b.
Measles (rubeola)
c.
Chickenpox (varicella)
d.
Exanthema subitum (roseola)
ANS: B
Koplik spots are small irregular red spots with a minute, bluish white center found on the buccal mucosa 2
days before systemic rash. Rubella occurs with rash on the face, which rapidly spreads downward. Varicella
appears with highly pruritic macules, followed by papules and vesicles. Roseola is seen with rose-pink macules
on the trunk, spreading to face and extremities.
PTS: 1 DIF: Cognitive Level: Apply REF: 397
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
9. Which is a common childhood communicable disease that may cause severe defects in the fetus when it
occurs in its congenital form?
a.
Erythema infectiosum
b.
Roseola
c.
Rubeola
d.
Rubella
ANS: D
Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in contact with
children affected with fifth disease. Roseola and rubeola are not dangerous to the fetus.
PTS: 1 DIF: Cognitive Level: Understand REF: 399
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
10. Which is the causative agent of scarlet fever?
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a.
Enteroviruses
b.
Corynebacterium organisms
c.
Scarlet fever virus
d.
Group A -hemolytic streptococci (GABHS)
179
ANS: D
GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications. Corynebacterium
organisms cause diphtheria. Scarlet fever is not caused by a virus.
PTS: 1 DIF: Cognitive Level: Understand REF: 399
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
11. A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with purulent drainage
and crusting of the eyelids, especially on awakening. These manifestations suggest:
a.
viral conjunctivitis.
b.
allergic conjunctivitis.
c.
bacterial conjunctivitis.
d.
conjunctivitis caused by foreign body.
ANS: C
Bacterial conjunctivitis has these symptoms. Viral or allergic conjunctivitis has watery drainage. Foreign body
causes tearing and pain, and usually only one eye is affected.
PTS: 1 DIF: Cognitive Level: Analyze REF: 403
TOP:Integrated Process: Nursing Process: Evaluation
MSC:Area of Client Needs: Physiologic Integrity
12. Which is an important nursing consideration when caring for a child with herpetic gingivostomatitis
(HGS)?
a. Apply topical anesthetics before eating.
b. Drink from a cup, not a straw.
c. Wait to brush teeth until lesions are sufficiently healed.
d. Explain to parents how this is sexually transmitted.
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ANS: A
Treatment for HGS is aimed at relief of pain. Drinking bland fluids through a straw helps avoid painful lesions.
Mouth care is encouraged with a soft toothbrush. HGS is usually caused by herpes simplex virus type 1, which
is not associated with sexual transmission.
PTS: 1 DIF: Cognitive Level: Apply REF: 404
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
13. A parent has asked the nurse about how her child can be tested for pinworms. The nurse responds by
stating that which is the most common test for diagnosing pinworms in a child?
a. Lower gastrointestinal (GI) series
b. Three stool specimens, at intervals of 4 days
c. Observation for presence of worms after child defecates
d. Laboratory examination of a fecal smear
ANS: D
Laboratory examination of substances containing the worm, its larvae, or ova can identify the organism. Most
are identified by examining fecal smears from the stools of persons suspected of harboring the parasite. Fresh
specimens are best for revealing parasites or larvae. Lower GI series is not helpful for diagnosing enterobiasis.
Stool specimens are not necessary to diagnose pinworms. Worms will not be visible after child defecates.
PTS: 1 DIF: Cognitive Level: Understand REF: 404
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Physiologic Integrity
14. The nurse suspects that a child has ingested some type of poison. Which clinical manifestation would be
most suggestive that the poison was a corrosive product?
a.
Tinnitus
b.
Disorientation
c.
Stupor, lethargy, coma
d.
Edema of lips, tongue, pharynx
ANS: D
Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion.
Corrosives do not act on the central nervous system (CNS).
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PTS: 1 DIF: Cognitive Level: Analyze REF: 408
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
15. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The
nurse taking the call should know that the primary danger is which result?
a.
Hepatic dysfunction
b.
Dehydration secondary to vomiting
c.
Esophageal stricture and shock
d.
Bronchitis and chemical pneumonia
ANS: D
Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not
hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late
or chronic issue of hydrocarbon ingestion.
PTS: 1 DIF: Cognitive Level: Apply REF: 409
TOP:Integrated Process: Nursing Process: Diagnosis
MSC:Area of Client Needs: Physiologic Integrity
16. Which is a clinical manifestation of acetaminophen poisoning?
a.
Hyperpyrexia
b.
Hepatic involvement
c.
Severe burning pain in stomach
d.
Drooling and inability to clear secretions
ANS: B
Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body
temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in
stomach or pose an airway threat.
PTS: 1 DIF: Cognitive Level: Understand REF: 409
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
17. Acute salicylate (ASA, aspirin) poisoning results in:
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Test Bank - Wong's Essentials of Pediatric Nursing (10th Edition by Hockenberry)
a.
chemical pneumonitis.
b.
hepatic damage.
c.
retractions and grunting.
d.
disorientation and loss of consciousness.
182
ANS: D
ASA poisoning causes disorientation and loss of consciousness. Chemical pneumonitis is caused by
hydrocarbon ingestion. Hepatic damage is caused by acetaminophen overdose. ASA does not cause airway
obstruction.
PTS: 1 DIF: Cognitive Level: Understand REF: 409
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
18. A young child has just arrived at the emergency department after ingestion of aspirin at home. The
practitioner has ordered activated charcoal. The nurse administers charcoal in which way?
a. Administer through a nasogastric tube because the child will not drink it because of the taste.
b. Serve in a clear plastic cup so the child can see how much has been drunk.
c. Give half of the solution, and then give the other half in 1 hour.
d. Serve in an opaque container with a straw.
ANS: D
Although the activated charcoal can be mixed with a flavorful beverage, it will be black and resemble mud.
When it is served in an opaque container, the child does not have any preconceived ideas about its being
distasteful. The nasogastric tube should be used only in children without a gag reflex. The ability to see the
charcoal solution may affect the childs desire to drink it. The child should be encouraged to drink the solution
all at once.
PTS: 1 DIF: Cognitive Level: Apply REF: 411
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
19. Which is the most frequent source of acute childhood lead poisoning?
a.
Folk remedies
b.
Unglazed pottery
c.
Lead-based paint
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d.
183
Cigarette butts and ashes
ANS: C
Lead-based paint in houses built before 1978 is the most frequent source of lead poisoning. Some folk
remedies and unglazed pottery may contain lead, but they are not the most frequent source. Cigarette butts and
ashes do not contain lead.
PTS: 1 DIF: Cognitive Level: Understand REF: 412
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
20. Chelation therapy for lead poisoning is initiated when a childs blood level is _____ g/dl.
a.
10 to 14
b.
15 to 19
c.
20 to 44
d.
>45
ANS: D
Chelation therapy is initiated if the childs blood level is greater than 45 g/dl. At 10 to 14 g/dl, the family should
have lead-poisoning education and follow-up level. At 15 to 19 g/dl, the family should have lead-poisoning
education and follow-up level but if it persists, initiate environmental investigation. At 20 to 44 g/dl
environmental investigation and lead hazard control are necessary.
PTS: 1 DIF: Cognitive Level: Apply REF: 415
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
21. Which describes a child who is abused by the parent(s)?
a. Unintentionally contributes to the abusing situation
b. Belongs to a low socioeconomic population
c. Is healthier than the nonabused siblings
d. Abuses siblings in the same way as child is abused by the parent(s)
ANS: A
Childs temperament, position in the family, additional physical needs, activity level, or degree of sensitivity to
parental needs unintentionally contribute to the abusing situation. Abuse occurs among all socioeconomic
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184
levels. Children who are ill or have additional physical needs are more likely to be abused. The abused child
may not abuse siblings.
PTS: 1 DIF: Cognitive Level: Understand REF: 418
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
22. Which is a common characteristic of those who sexually abuse children?
a. Pressure victim into secrecy
b. Are usually unemployed and unmarried
c. Are unknown to victims and victims families
d. Have many victims that are each abused once only
ANS: A
Sex offenders may pressure the victim into secrecy regarding the activity as a secret between us that other
people may take away if they find out. The offender may be anyone, including family members and persons
from any level of society. Sex offenders are usually trusted acquaintances of the victims and victims families.
Many victims are abused many times over a long period.
PTS: 1 DIF: Cognitive Level: Understand REF: 418
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
23. A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and
retinal hemorrhages but no external signs of trauma. The nurse should suspect:
a.
unintentional injury.
b.
shaken-baby syndrome.
c.
sudden infant death syndrome (SIDS).
d.
congenital neurologic problem.
ANS: B
Shaken-baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would
not cause these injuries. SIDS and congenital neurologic problems would not appear this way.
PTS: 1 DIF: Cognitive Level: Analyze REF: 417
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
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24. Which is probably the most important criterion on which to base the decision to report suspected child
abuse?
a. Inappropriate parental concern for the degree of injury
b. Absence of parents for questioning about childs injuries
c. Inappropriate response of child
d. Incompatibility between the history and injury observed
ANS: D
Conflicting stories about the accident are the most indicative red flags of abuse. Inappropriate response of
caregiver or child may be present, but is subjective. Parents should be questioned at some point during the
investigation.
PTS: 1 DIF: Cognitive Level: Apply REF: 420
TOP:Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
25. A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication should the
nurse expect to be prescribed?
a.
Metronidazole (Flagyl)
b.
Amoxicillin clavulanate (Augmentin)
c.
Clarithromycin (Biaxin)
d.
Prednisone (Orapred)
ANS: A
The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole (Tindamax), and
nitazoxanide (Alinia). These are classified as antifungals. Amoxicillin and clarithromycin are antibiotics that
treat bacterial infections. Prednisone is a steroid and is used as an anti-inflammatory medication.
PTS: 1 DIF: Cognitive Level: Apply REF: 406
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Physiologic Integrity
26. A nurse is beginning chelation therapy on a child for lead poisoning. Which intervention should the nurse
implement during the time the child is receiving chelation therapy?
a.
Calorie counts
b.
Strict intake and output
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c.
Telemetry monitoring
d.
Contact isolation
186
ANS: B
Because calcium disodium edetate (EDTA) and lead are toxic to the kidneys, a nurse should keep strict records
of intake and output to monitor renal functioning. Adequate hydration is essential during therapy because the
chelates are excreted via the kidneys. Calorie counts, telemetry, or contact isolation would not be nursing
interventions appropriate for a child undergoing chelation therapy.
PTS: 1 DIF: Cognitive Level: Apply REF: 415
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
27. A child has been admitted to the emergency department with an acetaminophen (Tylenol) poisoning. An
antidote is being prescribed by the health care provider. Which antidote should the nurse prepare to administer?
a.
Naloxone (Narcan)
b.
N-acetylcysteine (Mucomyst)
c.
Flumazenil (Romazicon)
d.
Digoxin immune Fab (Digibind)
ANS: B
Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen poisoning, naloxone
for opioid overdose, flumazenil (Romazicon) for benzodiazepines (diazepam [Valium], midazolam [Versed])
overdose, and digoxin immune Fab (Digibind) for digoxin toxicity.
PTS: 1 DIF: Cognitive Level: Apply REF: 411
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Physiologic Integrity
28. A clinic nurse is assessing a child with erythema infectiosum (fifth disease). Which figure depicts the rash
the nurse should expect to assess?
a.
c.
b.
d.
ANS: A
Erythema infectiosum rash appears in three stages: erythema on face, chiefly on cheeks (slapped face
appearance); disappears by 1-4 days. Chicken pox rash begins as macule, rapidly progresses to papule and then
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vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts);
all three stages (papule, vesicle, crust) present in varying degrees at one time. Roseola rash is discrete rose-pink
macules or maculopapules appearing first on trunk and then spreading to neck, face, and extremities;
nonpruritic; fades on pressure; lasts 1-2 days. Rubeola rashappears 3-4 days after onset of prodromal stage;
begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in
earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3-4 days, assumes
brownish appearance, and fine desquamation occurs over area of extensive involvement.
PTS: 1 DIF: Cognitive Level: Apply REF: 396
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. A nurse is teaching parents methods to reduce lead levels in their home. Which should the nurse include in
the teaching? (Select all that apply.)
a. Plant bushes around the outside of the house.
b. Ensure your child eats frequent meals.
c. Use hot water from the tap when boiling vegetables.
d. Food can be stored in ceramic in the refrigerator.
e. Ensure that your childs diet contains sufficient iron and calcium.
ANS: A, B, E
Methods to reduce lead levels in homes include: planting bushes around the outside of the house, if soil is
contaminated with lead, so children cannot play there; ensuring that children eat regular meals because more
lead is absorbed on an empty stomach; and ensuring that childrens diets contain sufficient iron and calcium.
Cold water should only be used for drinking, cooking, and reconstituting powder infant formula. Hot water
dissolves lead more quickly than cold water and thus contains higher levels of lead. Do not use pottery or
ceramic ware that was inadequately fired or is meant for decorative use for food storage or service.
PTS: 1 DIF: Cognitive Level: Apply REF: 416
TOP:Integrated Process: Teaching/Learning
MSC:Area of Client Needs: Health Promotion and Maintenance
ESSAY
1. Place in order the correct sequence for emergency treatment of poisoning in a child. Provide answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Locate the poison.
b. Assess the child.
c. Prevent absorption of poison.
d. Terminate exposure to the toxic substance.
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ANS:
b, d, a, c
The initial step in treating poisonings is to assess the child, treat immediate life-threatening conditions, and
initiate cardiopulmonary resuscitation (CPR) if indicated. Terminating the exposure to the toxic substance is
the second step. Locating the poison for identification is the third step. Preventing absorption of poison is the
fourth step.
PTS: 1 DIF: Cognitive Level: Apply REF: 408
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Physiologic Integrity
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Chapter 14: Health Promotion of the School-Age Child and Family
MULTIPLE CHOICE
1. The nurse is teaching a group of 10- to 12-year-old children about physical development during the schoolage years. Which statement made by a participant, indicates the correct understanding of the teaching?
a. My body weight will be almost triple in the next few years.
b. I will grow an average of 2 inches per year from this point on.
c. There are not that many physical differences 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: 430
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: 431
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: 432
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.
ANS: C
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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: 432
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: 432
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: 432
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Parents ask the nurse whether it is common for their school-age child to spend a lot of time with peers. The
nurse should respond, explaining that the role of the peer group in the life of 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
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: 434
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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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. Peergroup 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: 434
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: 435
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
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: 434
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
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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: 438
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: 439
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. Which statement best describes fear in the school-age child?
a. They are increasingly fearful for body safety.
b. Most of the new fears that trouble them are 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 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: 439
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
14. The father of a 12-year-old child tells the nurse that he is concerned about his son getting fat. His son is at
the 50th percentile for height and the 75th percentile for weight on the growth chart. 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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 438
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: 443
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
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: 443
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: 444
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.
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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: 445
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
19. A nurse is teaching parents of kindergarten children general guidelines to assist their children in school.
Which statement by the parents indicates they understand the teaching?
a. We will only meet with the teacher if problems occur.
b. We will discourage hobbies so our child 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: 439
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: 442
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: 440
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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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
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: 432
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: 435
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse teaches parents that team play is important for school-age children. Which can children develop by
experiencing team play? (Select all that apply.)
a. Achieve personal goals over group goals.
b. Learn complex rules.
c. Experience competition.
d. Learn about division of labor.
ANS: B, C, D
Team play helps stimulate cognitive growth because children are called on to learn many complex rules, make
judgments about those rules, plan strategies, and assess the strengths and weaknesses of members of their own
team and members of the opposing team. Team play can also contribute to 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 435
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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Chapter 15: Health Promotion of the Adolescent and Family
MULTIPLE CHOICE
1. In girls, the initial indication of puberty is:
a. menarche.
b. growth spurt.
c. growth of pubic hair.
d. breast development.
ANS: D
In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche.
The usual sequence of secondary sex characteristic development in girls is breast changes, rapid increase in
height and weight, growth of pubic hair, appearance of axillary hair, menstruation, and abrupt deceleration of
linear growth.
PTS: 1 DIF: Cognitive Level: Understand REF: 449
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: 450
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: 450
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
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The apocrine sweat glands, nonfunctional in children, reach secretory capacity during puberty. They secrete a
thick substance as a result of emotional stimulation that, when acted on by surface bacteria, becomes highly
odoriferous. They are limited in distribution and grow in conjunction with hair follicles, in the axilla, genital,
anal, and other areas. Eccrine sweat glands are present almost everywhere on the skin and become fully
functional and respond to emotional and thermal stimulation. Sebaceous glands become extremely active at
this time, especially those on the genitalia and the flush areas of the body such as face, neck, shoulders, upper
back, and chest. This increased activity is important in the development of acne. New deposits of fatty tissue is
not the etiology of apocrine sweat gland activity.
PTS: 1 DIF: Cognitive Level: Understand REF: 451
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: 453
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A nurse is planning a teaching session for a group of adolescents. The nurse understands that by adolescence
the individual is in which stage of cognitive development?
a. Formal operations
b. 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: 454
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
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: 454
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
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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 protectiondependency 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: 455
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 selfidentified 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: 458
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.
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: 459
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.
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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: 450
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: 462
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
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: 459
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: 450
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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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: 453
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.
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: 454
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: 455
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
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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: 461
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A 13-year-old is being seen in the clinic for a routine health check. The adolescent has not been in the clinic
for 3 years but was up to date on immunizations at that time. Which immunizations should the adolescent
receive? (Select all that apply.)
a. DTaP (tetanus, diphtheria, acellular pertussis)
b. MMR (measles, mumps, rubella)
c. Hepatitis B
d. Influenza
e. MCV4 (meningococcal)
ANS: A, D, E
The DTaP (tetanus, diphtheria, acellular pertussis) vaccine is recommended for adolescents 11 to 18 years old
who have not received a tetanus booster (Td) or DTaP dose and have completed the childhood DTaP/DTP
series. Meningococcal vaccine (MCV4) should be given to adolescents 11 to 12 years of age with a booster
dose at age 16 years. Annual influenza vaccination with either the live attenuated influenza vaccine or trivalent
influenza vaccine is recommended for all children and adolescents. The adolescent, previously up to date on
vaccinations, would have received the MMR and hepatitis B as a child.
PTS: 1 DIF: Cognitive Level: Apply REF: 460
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: 464
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 463
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: 461
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 450
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
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Chapter 16: Health Problems of School-Age Children and Adolescents
MULTIPLE CHOICE
1. Which statement is true about smoking in adolescence?
a. Smoking is related to other high-risk behaviors.
b. Smoking will not continue unless peer pressure continues.
c. Smoking is less common when the adolescents parent(s) smokes.
d. Smoking among adolescents is becoming more prevalent.
ANS: A
Cigarettes are considered a gateway drug. Teenagers who smoke are 11.4 times more likely to use an illicit
drug. Teenagers begin smoking for a variety of reasons, such as imitation of adult behavior, peer pressure,
imitation of behaviors portrayed in movies and advertisements, and a desire to control weight. The absence of
peer pressure alone will not stop smoking. Teenagers who do not smoke usually have parents and friends who
do not smoke or who oppose smoking. The percentage of young people who report current cigarette use and
frequent cigarette use has declined significantly.
PTS: 1 DIF: Cognitive Level: Understand REF: 495
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Smokeless tobacco is:
a. not addicting.
b. proven to be carcinogenic.
c. easy to stop using.
d. a safe alternative to cigarette smoking.
ANS: B
Smokeless tobacco is a popular substitute for cigarettes and poses serious health hazards to children and
adolescents. Smokeless tobacco is associated with cancer of the mouth and jaw. The nicotine in the smokeless
tobacco is addicting, and therefore it is very difficult to quit. Because the product is addicting and can cause
cancer, it is not a safe alternative to cigarette smoking.
PTS: 1 DIF: Cognitive Level: Remember REF: 496
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A child has been diagnosed with enuresis. TCA imipramine (Tofranil) has been prescribed for the child. The
nurse understands that this medication is in which category?
a. Antidepressant
b. Antidiuretic
c. Antispasmodic
d. Analgesic
ANS: C
Drug therapy is increasingly being prescribed to treat enuresis. Three types of drugs are used: tricyclic
antidepressants (TCAs), antidiuretics, and antispasmodics. The selection depends on the interpretation of the
cause. The drug used most frequently is the TCA imipramine (Tofranil), which exerts an anticholinergic action
in the bladder to inhibit urination. Tofranil is in the antispasmodic category. Analgesics are not used to treat
enuresis.
PTS: 1 DIF: Cognitive Level: Remember REF: 467
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
4. A 12-year-old male has short stature because of a constitutional growth delay. The nurse should be the most
concerned about which of the following?
a. Proper administration of thyroid hormone
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b. Proper administration of human growth hormones
c. Childs self-esteem and sense of competence
d. Helping child understand that his height is most likely caused by chronic illness and is not his fault
ANS: C
Most cases of constitutional growth delay are caused by simple constitutional delay of puberty, and the child
can be assured that normal development will eventually take place. Listening to distressed adolescents and
conveying interest and concern are important interventions for these children and adolescents. They should be
encouraged to focus on the positives aspects of their bodies and personalities. Thyroid hormones and human
growth hormones would not be beneficial in a constitutional growth delay. A constitutional growth delay is not
caused by a chronic illness.
PTS: 1 DIF: Cognitive Level: Understand REF: 475
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
5. Which syndrome involves a common sex chromosome defect?
a. Down
b. Turner
c. Marfan
d. Hemophilia
ANS: B
Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy
21, three copies rather than two copies of chromosome 21. Marfan syndrome is a connective tissue disorder
inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an Xlinked recessive pattern.
PTS: 1 DIF: Cognitive Level: Understand REF: 475
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. Turner syndrome is suspected in an adolescent girl with short stature. This is caused by:
a. absence of one of the X chromosomes.
b. presence of an incomplete Y chromosome.
c. precocious puberty in an otherwise healthy child.
d. excess production of both androgens and estrogens.
ANS: A
Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder
have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner
syndrome. This young woman has 45 rather than 46 chromosomes.
PTS: 1 DIF: Cognitive Level: Understand REF: 475
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. An adolescent asks the nurse what causes primary dysmenorrhea. The nurses response should be based on
which statement?
a. It is an inherited problem.
b. Excessive estrogen production causes uterine pain.
c. There is no physiologic cause; it is a psychological reaction.
d. There is a relation between prostaglandins and uterine contractility.
ANS: D
The exact etiology of primary dysmenorrhea is debated. Overproduction of uterine prostaglandins has been
implicated, as has overproduction of vasopressin. Dysmenorrhea is not known to be inherited. Excessive
estrogen has not been implicated in the etiology. It has a physiologic cause. Women with dysmenorrhea have
higher prostaglandin levels.
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PTS: 1 DIF: Cognitive Level: Apply REF: 476
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. An adolescent girl asks the school nurse for advice because she has dysmenorrhea. She says that a friend
recommended she try an over-the-counter nonsteroidal anti-inflammatory drug (NSAID). The nurses response
should be based on which statement?
a. Aspirin is the drug of choice for the treatment of dysmenorrhea.
b. Over-the-counter NSAIDs are rarely strong enough to provide adequate pain relief.
c. NSAIDs are effective because of their analgesic effect.
d. NSAIDs are effective because they inhibit prostaglandins, leading to reduction in uterine activity.
ANS: D
First-line therapy for adolescents with dysmenorrhea is NSAIDs. This group of drugs blocks the formation of
prostaglandins. NSAIDs, not aspirin, are the drugs of choice in dysmenorrhea. NSAIDs are potent antiinflammatory agents that inhibit prostaglandin. Although NSAIDs have analgesic effects, the mechanism of
action in dysmenorrhea is most likely the antiprostaglandin effect.
PTS: 1 DIF: Cognitive Level: Apply REF: 476
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
9. The school nurse is discussing testicular self-examination with adolescent boys. Why is this important?
a. Epididymitis is common during adolescence.
b. Asymptomatic sexually transmitted diseases may be present.
c. Testicular tumors during adolescence are generally malignant.
d. Testicular tumors, although usually benign, are common during adolescence.
ANS: C
Tumors of the testes are not common, but when manifested in adolescence, they are generally malignant and
demand immediate evaluation. Epididymitis is not common in adolescence. Asymptomatic sexually
transmitted disease would not be evident during testicular self-examination. The focus of this examination is
on testicular cancer. Testicular tumors are most commonly malignant.
PTS: 1 DIF: Cognitive Level: Apply REF: 478
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. Which is the usual presenting symptom for testicular cancer?
a. Hard, painful mass
b. Hard, painless mass
c. Epididymis easily palpated
d. Scrotal swelling and pain
ANS: B
The usual presenting symptom for testicular cancer is a heavy, hard, painless mass that is either smooth or
nodular and palpated on the testes. A hard, painful mass, an epididymis easily palpated, and scrotal swelling
and pain are not the clinical presentations of testicular cancer.
PTS: 1 DIF: Cognitive Level: Understand REF: 477
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. A 14-year-old boy and his parents are concerned about bilateral breast enlargement. The nurses discussion
of this should be based on which statement?
a. This is usually benign and temporary.
b. This is usually caused by Klinefelter syndrome.
c. Administration of estrogen effectively reduces gynecomastia.
d. Administration of testosterone effectively reduces gynecomastia.
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ANS: A
The male breast responds to hormonal changes. Some degree of bilateral or unilateral breast enlargement
occurs frequently in boys during puberty. Although individuals with Klinefelter syndrome can have
gynecomastia, it is not a common cause for male breast enlargement. Estrogen is not a therapy for
gynecomastia. Administration of testosterone has no benefit for gynecomastia and may aggravate the
condition.
PTS: 1 DIF: Cognitive Level: Understand REF: 478
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She
has not received any medical care. She smokes but denies any other substance use. The priority nursing action
is to:
a. notify her parents.
b. refer for prenatal care.
c. explain the importance of not smoking.
d. discuss dietary needs for adequate fetal growth.
ANS: B
Teenage girls and their unborn children are at greater risk for complications during pregnancy and delivery.
With improved therapies, the mortality for teenage pregnancy is decreasing, but the morbidity is high. A
pregnant teenager needs careful assessment by the nurse to determine the level of social support available to
her and possibly her partner. Guidance from the adults in her life would be invaluable, but confidentiality
should be maintained. Although it is important to explain the importance of not smoking and to discuss dietary
needs for adequate fetal growth, because of her potential for having a high-risk pregnancy, she will need a
comprehensive prenatal program to minimize maternal-fetal complications.
PTS: 1 DIF: Cognitive Level: Apply REF: 478
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does
not want to be pregnant. The nurse should explain that:
a. it is too late to prevent an unwanted pregnancy.
b. an abortion may be the best option if she is pregnant.
c. Norplant can be administered to prevent pregnancy for up to 5 years.
d. postcoital contraception is available to prevent implantation.
ANS: D
Several emergency methods of contraception are available. Postcoital contraception options do exist. It is
nontherapeutic to tell her it is too late or that an abortion is the best option. Norplant is not a postcoital
contraceptive.
PTS: 1 DIF: Cognitive Level: Apply REF: 482
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. A sexually active female adolescent asks the nurse about the contraceptive Depo-Provera. The nurse should
explain that it:
a. requires injections every 3 months.
b. requires daily administration of medication by mouth.
c. provides long-term continuous protection, up to 5 years.
d. prevents pregnancy if given within 72 hours of unprotected sex.
ANS: A
The contraceptive Depo-Provera is administered by injection every 3 months. Oral contraceptives, not DepoProvera, require daily administration of medication by mouth. Norplant, not Depo-Provera, provides long-term
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continuous protection for up to 5 years. Postcoital contraception, not Depo-Provera, prevents pregnancy if
given within 72 hours of unprotected sex.
PTS: 1 DIF: Cognitive Level: Understand REF: 479
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. Which statement is true about gonorrhea?
a. It is caused by Treponema pallidum.
b. Treatment is by multidose administration of penicillin.
c. Treatment is by topical applications to lesions.
d. Treatment of all sexual contacts is an essential part of treatment.
ANS: D
The treatment plan should include finding and treating all sexual partners. Gonorrhea is caused by Neisseria
gonorrhoeae. Syphilis is caused by T. pallidum. Primary treatment is with different antibiotics because of N.
gonorrhoeae resistance to penicillin. Systemic therapy is necessary to treat this disease.
PTS: 1 DIF: Cognitive Level: Understand REF: 483
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. Which statement regarding chlamydia infection is correct?
a. Treatment of choice is oral penicillin.
b. Treatment of choice is nystatin or miconazole.
c. Clinical manifestations include dysuria and urethral itching in males.
d. Clinical manifestations include small, painful vesicles on genital areas.
ANS: C
Symptoms of chlamydia infection in males include meatal erythema, tenderness, itching, dysuria, and urethral
discharge. Some infected males have no symptoms. Oral penicillin and nystatin or miconazole are not the
antibiotics of choice. Small, painful vesicles on genital areas are clinical manifestations true of chlamydia
infection but may also indicate herpetic lesions.
PTS: 1 DIF: Cognitive Level: Understand REF: 483
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. A nurse is conducting a class for adolescent girls about pelvic inflammatory disease (PID). Why should the
nurse emphasize the importance of preventing pelvic inflammatory disease (PID)?
a. PID can be sexually transmitted.
b. PID cannot be treated.
c. PID can have devastating effects on the reproductive tract.
d. PID can cause serious defects in future children of affected adolescents.
ANS: C
PID is a major concern because of its devastating effects on the reproductive tract. Short-term complications
include abscess formation in the fallopian tubes, whereas long-term complications include ectopic pregnancy,
infertility, and dyspareunia. PID is an infection of the upper female genital tract, most commonly caused by
sexually transmitted infections but it is not sexually transmitted to another person. PID can be treated by
treating the underlying cause. There is a possibility of ectopic pregnancy but not birth defects in children.
PTS: 1 DIF: Cognitive Level: Apply REF: 482
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. Which statement is correct about childhood obesity?
a. Heredity is an important factor in the development of obesity.
b. Childhood obesity in the United States is decreasing.
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c. Childhood obesity is the result of inactivity.
d. Childhood obesity can be attributed to an underlying disease in most cases.
ANS: A
Heredity is an important fact that contributes to obesity. Identical twins reared apart tend to resemble their
biologic parents to a greater extent than their adoptive parents. It is difficult to distinguish between hereditary
and environmental factors. The number of overweight children is increasing in the United States. Inactivity is
related to childhood obesity, but it is not the only component. Underlying diseases such as hypothyroidism and
hyperinsulinism account for only a small number of cases of childhood obesity.
PTS: 1 DIF: Cognitive Level: Understand REF: 486
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
19. The psychological effects of being obese during adolescence include:
a. sexual promiscuity.
b. poor body image.
c. feelings of contempt for thin peers.
d. accurate body image but self-deprecating attitude.
ANS: B
Common emotional consequences of obesity include poor body image, low self-esteem, social isolation, and
feelings of depression and isolation. Sexual promiscuity, feelings of contempt for thin peers, and accurate body
image but self-deprecating attitude are not usually associated with obesity.
PTS: 1 DIF: Cognitive Level: Understand REF: 487
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
20. Anorexia nervosa may best be described as:
a. occurring most frequently in adolescent males.
b. occurring most frequently in adolescents from lower socioeconomic groups.
c. resulting from a posterior pituitary disorder.
d. resulting in severe weight loss in the absence of obvious physical causes.
ANS: D
The etiology of anorexia remains unclear, but a distinct psychological component is present. The diagnosis is
based primarily on psychological and behavioral criteria. Females account for 90% to 95% of the cases. No
relation has been identified between socioeconomic groups and anorexia. Posterior pituitary disorders are not
associated with anorexia nervosa.
PTS: 1 DIF: Cognitive Level: Remember REF: 490
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. Young people with anorexia nervosa are often described as being:
a. independent.
b. disruptive.
c. conforming.
d. low achieving.
ANS: C
Individuals with anorexia nervosa are described as perfectionist, academically high achievers, conforming, and
conscientious. Independent, disruptive, and low achieving are not part of the behavioral characteristics of
anorexia nervosa.
PTS: 1 DIF: Cognitive Level: Understand REF: 490
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
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22. The weight loss of anorexia nervosa is usually triggered by
a. sexual abuse.
b. school failure.
c. independence from family.
d. traumatic interpersonal conflict.
ANS: D
Weight loss may be triggered by a typical adolescent crisis such as the onset of menstruation or a traumatic
interpersonal incident; situations of severe family stress, such as parental separation or divorce; or
circumstances in which the young person lacks personal control, such as being teased, changing schools, or
entering college. Sexual abuse, school failure, and independence from family are not part of the behavioral
characteristics of anorexia nervosa.
PTS: 1 DIF: Cognitive Level: Understand REF: 491
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
23. Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl
with severe weight loss and disrupted metabolism associated with anorexia nervosa?
a. Dysmenorrhea and oliguria
b. Tachycardia and tachypnea
c. Heat intolerance and increased blood pressure
d. Lowered body temperature and brittle nails
ANS: D
Symptoms of anorexia nervosa include lower body temperature, severe weight loss, decreased blood pressure,
dry skin, brittle nails, altered metabolic activity, and presence of lanugo hair. Amenorrhea, rather than
dysmenorrhea, and cold intolerance are manifestations of anorexia nervosa. Bradycardia, rather than
tachycardia, may be present.
PTS: 1 DIF: Cognitive Level: Understand REF: 491
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. Which is descriptive of bulimia during adolescence?
a. Strong sense of control over eating behavior
b. Feelings of elation after the binge-purge cycle
c. Profound lack of awareness that the eating pattern is abnormal
d. Weight that can be normal, slightly above normal, or below normal
ANS: D
Individuals with bulimia are of normal or more commonly slightly above normal weight. Those who also
restrict their intake can become severely underweight. The adolescent has a lack of control over eating during
the episode. Patients with bulimia commonly have self-deprecating thoughts and a depressed mood after bingepurge cycles; they are also aware that the eating pattern is abnormal but are unable to stop.
PTS: 1 DIF: Cognitive Level: Understand REF: 490
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
25. An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?
a. Diarrhea
b. Amenorrhea
c. Cold intolerance
d. Erosion of tooth enamel
ANS: D
Some of the signs of bulimia include erosion of tooth enamel, increased dental caries from vomited gastric
acid, throat complaints, fluid and electrolyte disturbances, and abdominal complaints from laxative abuse.
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Diarrhea is not a result of the vomiting. It may occur in patients with bulimia who also abuse laxatives.
Amenorrhea and cold intolerance are characteristics of anorexia nervosa, which some bulimics have. These
symptoms are related to the extreme low weight.
PTS: 1 DIF: Cognitive Level: Apply REF: 490
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. Which is descriptive of attention deficit hyperactivity disorder (ADHD)?
a. Manifestations exhibited are so bizarre that the diagnosis is fairly easy.
b. Manifestations affect every aspect of the childs life but are most obvious in the classroom.
c. Learning disabilities associated with ADHD eventually disappear when adulthood is reached.
d. Diagnosis of ADHD requires that all manifestations of the disorder be present.
ANS: B
ADHD affects every aspect of the childs life, but the disruption is most obvious in the classroom. The
behaviors exhibited by the child with ADHD are not unusual aspects of behavior. The difference lies in the
quality of motor activity and developmentally inappropriate inattention, impulsivity, and hyperactivity that the
child displays. Some children experience decreased symptoms during late adolescence and adulthood, but a
significant number carry their symptoms into adulthood. Any given child will not have every symptom of the
condition. The manifestations may be numerous or few, mild or severe, and will vary with the childs
developmental level.
PTS: 1 DIF: Cognitive Level: Understand REF: 469
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. The nurse is teaching the parents of a child recently diagnosed with ADHD who has been prescribed
methylphenidate (Ritalin). Which should the nurse include in teaching about the side effects of
methylphenidate?
a. Your child may experience a sense of nervousness.
b. You may see an increase in your childs appetite.
c. Your child may experience daytime sleepiness.
d. You may see a decrease in your childs blood pressure.
ANS: A
Nervousness is one of the common side effects of Ritalin. Decreased appetite with subsequent weight loss,
insomnia, and increased blood pressure are other common side effects.
PTS: 1 DIF: Cognitive Level: Apply REF: 470
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
28. Which is an important consideration when the nurse is discussing enuresis with the parents of a young
child?
a. Enuresis is more common in girls than in boys.
b. Enuresis is neither inherited nor has a familial tendency.
c. Organic causes that may be related to enuresis should be considered first.
d. Psychogenic factors that cause enuresis persist into adulthood.
ANS: C
Organic causes that may be related to enuresis should be ruled out before psychogenic factors are considered.
Enuresis is more common in boys than in girls and has a strong familial tendency. Psychogenic factors may
influence enuresis, but it is doubtful that they are causative.
PTS: 1 DIF: Cognitive Level: Apply REF: 467
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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29. The nurse is assisting the family of a child with a history of encopresis. Which should be included in the
nurses discussion with this family?
a. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
b. Instruct the parents that the child will probably need to have daily enemas.
c. Suggest the use of stimulant cathartics weekly.
d. Reassure the family that most problems are resolved successfully, with some relapses during periods of
stress.
ANS: D
Children may be unaware of a prior sensation and unable to control the urge once it begins. They may be so
accustomed to bowel accidents that they are unable to smell or feel it. Family counseling is directed toward
reassurance that most problems resolve successfully, although relapses during periods of stress are possible.
Sitting the child on the toilet is not recommended because it may intensify the parent-child conflict. Enemas
may be needed for impactions, but long-term use prevents the child from assuming responsibility for
defecation. Stimulant cathartics may cause cramping that can frighten child.
PTS: 1 DIF: Cognitive Level: Apply REF: 469
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. A mother calls the school nurse saying that her daughter has developed a school phobia. She has been out
of school 3 days. The nurses recommendations should include which intervention?
a. Immediately return child to school.
b. Explain to child that this is the last day she can stay home.
c. Determine cause of phobia before returning child to school.
d. Seek professional counseling before forcing child to return to school.
ANS: A
The primary goal is to return the child to school. Parents must be convinced gently, but firmly, that immediate
return is essential and that it is their responsibility to insist on school attendance. The longer the child is
permitted to stay out of school, the more difficult it will be for the child to reenter. Trying to find the cause of
phobia will only delay the return to school and inhibit the childs ability to cope. Professional counseling is
recommended if the problem persists, but the childs return to school should not wait for the counseling.
PTS: 1 DIF: Cognitive Level: Apply REF: 473
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
31. Parents have a concern that their child is depressed. The nurse relates that which characteristic best
describes children with depression?
a. Increased range of affective response
b. Preoccupation with need to perform well in school
c. Change in appetite, resulting in weight loss or gain
d. Tendency to prefer play instead of schoolwork
ANS: C
Physiologic characteristics of children with depression include change in appetite resulting in weight loss or
gain, nonspecific complaints of not feeling well, alterations in sleeping pattern, insomnia or hypersomnia, and
constipation. Children who are depressed have sad facial expressions with absence or diminished range of
affective response. These children withdraw from previously enjoyed activities and engage in solitary play or
work with a lack of interest in play. A lack of interest is seen in doing homework or achieving in school,
resulting in lower grades in children who are depressed.
PTS: 1 DIF: Cognitive Level: Apply REF: 474
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
32. A teen asks a nurse, What is physical dependence in substance abuse? Which is the correct response by the
nurse?
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a. Problem that occurs in conjunction with addiction
b. Involuntary physiologic response to drug
c. Culturally defined use of drugs for purposes other than accepted medical purposes
d. Voluntary behavior based on psychosocial needs
ANS: B
Physical dependence is an involuntary response to the pharmacologic characteristics of drugs such as opioids
or alcohol. A person can be physically dependent on a narcotic/drug without being addicted; for example,
patients who use opioids to control pain need increasing doses to achieve the same effect. Dependence is a
physiologic response; it is not culturally determined or subject to voluntary control.
PTS: 1 DIF: Cognitive Level: Apply REF: 495
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
33. Which is descriptive of central nervous system stimulants?
a. They produce strong physical dependence.
b. They can result in strong psychological dependence.
c. Withdrawal symptoms are life threatening.
d. Acute intoxication can lead to coma.
ANS: B
Central nervous system stimulants such as amphetamines and cocaine produce a strong psychological
dependence. This class of drugs does not produce strong physical dependence and can be withdrawn without
much danger. Acute intoxication leads to violent, aggressive behavior or psychotic episodes characterized by
paranoia, uncontrollable agitation, and restlessness.
PTS: 1 DIF: Cognitive Level: Understand REF: 497
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
34. The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed
to be the drug involved. Data collection should include what information?
a. Mode of administration
b. Drugs actual content
c. Function the drug plays in the adolescents life
d. Adolescents level of interest in rehabilitation
ANS: A
When the drug is questionable or unknown, every effort must be made to determine the type, amount of drug
taken, the mode and time of administration, and factors relating to the onset of presenting symptoms. The
actual content of most street drugs is highly questionable. Pharmacologic agents should be administered with
caution, except for the narcotic antagonists in case of suspected opioid use. The function the drug plays in the
adolescents life and the adolescents level of interest in rehabilitation are important considerations in the longterm management during the nonacute stage.
PTS: 1 DIF: Cognitive Level: Apply REF: 496
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
35. A school nurse is conducting a class with adolescents on suicide. Which true statement about suicide
should the nurse include in the teaching session?
a. A sense of hopelessness and despair are a normal part of adolescence.
b. Gay and lesbian adolescents are at a particularly high risk for suicide.
c. Problem-solving skills are of limited value to the suicidal adolescent.
d. Previous suicide attempts are not an indication of risk for completed suicides.
ANS: B
A significant number of teenage suicides occur among homosexual youths. Gay and lesbian adolescents who
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live in families or communities that do not accept homosexuality are likely to suffer low self-esteem, selfloathing, depression, and hopelessness as a result of a lack of acceptance from their family or community. Atrisk teenagers include those who are depressed, have poor problem-solving skills, or use drugs and alcohol.
History of previous suicide attempt is a serious indicator for possible suicide completion in the future.
PTS: 1 DIF: Cognitive Level: Apply REF: 499
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
36. Which is the most commonly used method in completed suicides?
a. Firearms
b. Drug overdose
c. Self-inflected laceration
d. Carbon monoxide poisoning
ANS: A
Firearms are the most commonly used instruments in completed suicides among both males and females. For
adolescent boys, firearms are followed by hanging and overdose. For adolescent females, overdose and
strangulation are the next most common means of completed suicide. The most common method of suicide
attempt is overdose or ingestion of potentially toxic substances such as drugs. The second most common
method of suicide attempt is self-inflicted laceration. Carbon monoxide poisoning is not one of the more
frequent forms of suicide completion.
PTS: 1 DIF: Cognitive Level: Remember REF: 499
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
37. Which is the most significant factor in distinguishing those who commit suicide from those who make
suicidal attempts or threats?
a. Social isolation
b. Level of stress
c. Degree of depression
d. Desire to punish others
ANS: A
Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who
will not. It is also more characteristic of those who complete suicide than of those who make attempts or
threats. Level of stress, degree of depression, and desire to punish others are contributing factors in suicide, but
they are not the most significant factor in distinguishing those who complete suicide from those who attempt
suicide.
PTS: 1 DIF: Cognitive Level: Understand REF: 500
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
38. An adolescent girl tells the nurse that she is very suicidal. The nurse asks her whether she has a specific
plan. Asking this should be considered:
a. an appropriate part of the assessment.
b. not a critical part of the assessment.
c. suggesting that the adolescent needs a plan.
d. encouraging the adolescent to devise a plan.
ANS: A
Routine health assessments of adolescents should include questions that assess the presence of suicidal ideation
or intent. Questions such as, Have you ever developed a plan to hurt yourself or kill yourself? should be part of
that assessment. Adolescents who express suicidal feelings and have a specific plan are at particular risk and
require further assessment and constant monitoring. The information about having a plan is an essential part of
the assessment and greatly affects the treatment plan.
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PTS: 1 DIF: Cognitive Level: Understand REF: 499
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
39. An adolescent has been diagnosed with lactose maldigestion intolerance. The nurse teaches the adolescent
about lactose maldigestion intolerance and notes the teen needs further teaching if which statement is made?
a. I will limit my milk consumption to one to two glasses a day.
b. I should drink the milk alone and not with other foods.
c. Hard cheese, cottage cheese, or yogurt can be substituted for milk.
d. I will take a calcium supplement daily.
ANS: B
Most people are able to tolerate small amounts of lactose ( 1 cup of milk per day) even in the presence of
deficient lactase activity. It is recommended that individuals with lactose maldigestion who do not experience
lactose intolerance symptoms continue to consume small amounts of dairy products with meals to prevent
reduced bone mass density and subsequent osteoporosis. Hard cheese, cottage cheese, and yogurt are sources
of lactose that may be better tolerated. A calcium supplement should be taken daily. Milk taken at meals may
be better tolerated than when taken alone.
PTS: 1 DIF: Cognitive Level: Apply REF: 494
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
40. An adolescent has been diagnosed with Chlamydia infection. Which medication should the nurse expect to
be prescribed for this condition?
a. Ceftriaxone (Rocephin) IM
b. Azithromycin (Zithromax) PO
c. Acyclovir (Zovirax) PO
d. Penicillin G benzathine (Bicillin) IV
ANS: B
Azithromycin is used to treat Chlamydia. The patient should be rescreened in 3 to 4 months. Ceftriaxone is
used to treat gonorrhea, acyclovir is used to suppress genital herpes simplex virus, and penicillin G benzathine
is used to treat syphilis.
PTS: 1 DIF: Cognitive Level: Understand REF: 482
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. A nurse is recommending strategies to a group of school-age children for prevention of obesity. Which
should the nurse include? (Select all that apply.)
a. Eat breakfast daily.
b. Limit fruits and vegetables.
c. Have frequent family meals with parents present.
d. Eat frequently at restaurants.
e. Limit television viewing to 2 hours a day.
ANS: A, C, E
The nurse should counsel school-age children to eat breakfast daily, have mealtimes with family, and limit
television viewing to 2 hours a day to prevent obesity. Fruits and vegetables should be consumed in the
recommended quantities, and eating at restaurants should be limited.
PTS: 1 DIF: Cognitive Level: Analyze REF: 488
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which strategies should the school nurse recommend implementing in the classroom for a child with
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attention deficit hyperactive disorder (ADHD)? (Select all that apply.)
a. Schedule heavier subjects to be taught in the afternoon.
b. Accompany verbal instructions by written format.
c. Limit number of breaks taken during instructional periods.
d. Allow more time for testing.
e. Reduce homework and classroom assignments.
ANS: B, D, E
Children with ADHD need an orderly, predictable, and consistent classroom environment with clear and
consistent rules. Homework and classroom assignments may need to be reduced, and more time may need to
be allotted for tests to allow the child to complete the task. Verbal instructions should be accompanied by
visual references such as written instructions on the blackboard. Schedules may need to be arranged so that
academic subjects are taught in the morning when the child is experiencing the effects of the morning dose of
medication. Regular and frequent breaks in activity are helpful because sitting in one place for an extended
time may be difficult.
PTS: 1 DIF: Cognitive Level: Apply REF: 471
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which side effects should the nurse monitor when a child is taking an antipsychotic medication? (Select all
that apply.)
a. Extrapyramidal effects
b. Hypertension
c. Bradycardia
d. Dizziness
e. Seizures
ANS: A, D, E
Common side effects of antipsychotic medications include dizziness, drowsiness, tachycardia, hypotension,
and extrapyramidal effects, such as abnormal movements and seizures.
PTS: 1 DIF: Cognitive Level: Understand REF: 474
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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Chapter 17: Quality of Life for Children Living with Chronic or
Complex Diseases
MULTIPLE CHOICE
1. The nurse case manager is planning a care conference about a young child who has complex health care
needs and will soon be discharged home. Who should the nurse invite to the conference?
a. Family and nursing staff
b. Social worker, nursing staff, and primary care physician
c. Family and key health professionals involved in childs care
d. Primary care physician and key health professionals involved in the childs care
ANS: C
A multidisciplinary conference is necessary for coordination of care for children with complex health needs.
The family is included, along with key health professionals who are involved in the childs care. The nursing
staff can address the childs nursing care needs with the family, but other involved disciplines must be included.
The family must be included in the discharge conferences, which allows them to determine what education
they will require and the resources needed at home. A member of the nursing staff must be included to review
the childs nursing needs.
PTS: 1 DIF: Cognitive Level: Analyze REF: 503
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
2. Which represents a common best practice in the provision of services to children with special needs?
a. Care is now being focused on the childs chronologic age.
b. Children with special needs are being integrated into regular classrooms.
c. Children with special needs no longer have to be cared for by their families.
d. Children with special needs are being separated into residential treatment facilities.
ANS: B
Normalization refers to behaviors and interventions for the disabled to integrate into society by living life as
persons without a disability would. For children, normalization includes attending school and being integrated
into regular classrooms. This affords the child the advantages of learning with a wide group of peers. Care is
necessarily focused on the childs developmental age. Home care by the family is considered best practice. The
nurse can assist families by assessing social support systems, coping strategies, family cohesiveness, and
family and community resources.
PTS: 1 DIF: Cognitive Level: Understand REF: 504
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
3. Lindsey, age 5 years, will be starting kindergarten next month. She has cerebral palsy, and it has been
determined that she needs to be in a special education classroom. Her parents are tearful when telling the nurse
about this and state that they did not realize her disability was so severe. The best interpretation of this
situation is that:
a. this is a sign parents are in denial.
b. this is a normal anticipated time of parental stress.
c. the parents need to learn more about cerebral palsy.
d. the parents are used to having expectations that are too high.
ANS: B
Parenting a child with a chronic illness can be stressful for parents. There are anticipated times that parental
stress increases. One of these identified times is when the child begins school. Nurses can help parents
recognize and plan interventions to work through these stressful periods. The parents are not in denial; they are
responding to the childs placement in school. The parents are not exhibiting signs of a knowledge deficit; this
is their first interaction with the school system with this child.
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PTS: 1 DIF: Cognitive Level: Analyze REF: 505
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
4. Approach behaviors are those coping mechanisms that result in a familys movement toward adjustment and
resolution of the crisis of having a child with a chronic illness or disability. Which is considered an approach
behavior?
a. Is unable to adjust to a progression of the disease or condition
b. Anticipates future problems and seeks guidance and answers
c. Looks for new cures without a perspective toward possible benefit
d. Fails to recognize seriousness of childs condition despite physical evidence
ANS: B
The parents who anticipate future problems and seek guidance and answers are demonstrating approach
behaviors. They are demonstrating positive actions in caring for their child. Being unable to adjust to a
progression of the disease or condition, looking for new cures without a perspective toward possible benefit,
and failing to recognize seriousness of childs condition despite physical evidence are avoidance behaviors. The
parents are moving away from adjustment (and toward maladaptation) in the crisis of a child with chronic
illness or disability.
PTS: 1 DIF: Cognitive Level: Understand REF: 507
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
5. Families progress through various stages of reactions when a child is diagnosed with a chronic illness or
disability. After the shock phase, a period of adjustment usually follows. This is often characterized by which
of the following responses?
a. Denial
b. Guilt and anger
c. Social reintegration
d. Acceptance of childs limitations
ANS: B
For most families, the adjustment phase is accompanied by several responses. Guilt, self-accusation, bitterness,
and anger are common reactions. The initial diagnosis of a chronic illness or disability often is met with
intense emotion, characterized by shock and denial. Social reintegration and acceptance of the childs
limitations are the culmination of the adjustment process.
PTS: 1 DIF: Cognitive Level: Understand REF: 508
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
6. Which nursing intervention is especially helpful in assessing parental guilt when a disability or chronic
illness is diagnosed?
a. Ask the parents if they feel guilty.
b. Discuss guilt only after the parents mention it.
c. Discuss the meaning of the parents religious and cultural background.
d. Observe for signs of overprotectiveness.
ANS: C
Guilt may be associated with cultural or religious beliefs. Some parents are convinced that they are being
punished for some previous misdeed. Others may see the disorder as a sacrifice sent by God to test their
religious beliefs. The nurse can help the parents explore their religious beliefs. The parents may not be able to
identify the feelings of guilt. It would be appropriate for the nurse to explore their adjustment responses.
Overprotectiveness is a parental response during the adjustment phase. The parents fear letting the child
achieve any new skill and avoid all discipline.
PTS: 1 DIF: Cognitive Level: Apply REF: 508
TOP: Integrated Process: Nursing Process: Implementation
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MSC: Area of Client Needs: Psychosocial Integrity
7. The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse should
recognize that this is most likely an indication that the child is experiencing a:
a. sense of hopefulness.
b. sense of chronic sorrow.
c. belief that procedures are a deserved punishment.
d. belief that procedures are an important part of care.
ANS: C
The nurse should be particularly alert to the child who passively accepts all painful procedures. This child may
believe that such acts are inflicted as deserved punishment. The child who is hopeful is mobilized into goaldirected actions. This child would actively participate in care. Chronic sorrow is the feeling of sorrow and loss
that recurs in waves over time. It is usually evident in the parents, not in the child. A child who believes that
procedures are an important part of care would actively participate in care. Nursing interventions should be
used to minimize the pain.
PTS: 1 DIF: Cognitive Level: Analyze REF: 508
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
8. The nurse comes into the room of a child who was just diagnosed with a chronic disability. The childs
parents begin to yell at the nurse about a variety of concerns. Which is the nurses best response?
a. What is really wrong?
b. Being angry is only natural.
c. Yelling at me will not change things.
d. I will come back when you settle down.
ANS: B
Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most
common targets for parental anger is members of the staff. The nurse should recognize the common response
of anger to the diagnosis and allow the family to ventilate. What is really wrong?/Yelling at me will not change
things/I will come back when you settle down will place the parents on the defensive and not facilitate
communication.
PTS: 1 DIF: Cognitive Level: Apply REF: 516
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
9. A common parental reaction to a child with special needs is parental overprotection. Parental behavior
suggestive of this includes:
a. giving inconsistent discipline.
b. providing consistent, strict discipline.
c. forcing child to help self, even when not capable.
d. encouraging social and educational activities not appropriate to childs level of capability.
ANS: A
Parental overprotection is manifested by the parents fear of letting the child achieve any new skill; they allow
the child to avoid all discipline and cater to every desire to prevent frustration. Overprotective parents: do not
set limits and or institute discipline; prefer to remain in the role of total caregiver; do not allow the child to
perform self-care; and do not encourage the child to participate in social and educational activities.
PTS: 1 DIF: Cognitive Level: Analyze REF: 509
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
10. Most parents of children with special needs tend to experience chronic sorrow. This is characterized by:
a. lack of acceptance of childs limitation.
b. lack of available support to prevent sorrow.
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c. periods of intensified sorrow when experiencing anger and guilt.
d. periods of intensified sorrow and loss that occur in waves over time.
ANS: D
Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The sorrow is in
response to the recognition of the childs limitations. The family should be assessed in an ongoing manner to
provide appropriate support as the needs of the family change. The sorrow is not preventable. The chronic
sorrow occurs during the reintegration and acknowledgment stage.
PTS: 1 DIF: Cognitive Level: Understand REF: 509
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
11. Which intervention will encourage a sense of autonomy in a toddler with disabilities?
a. Avoid separation from family during hospitalizations.
b. Encourage independence in as many areas as possible.
c. Expose child to pleasurable experiences as much as possible.
d. Help parents learn special care needs of their child.
ANS: B
Encouraging the toddler to be independent encourages a sense of autonomy. The child can be given choices
about feeding, dressing, and diversional activities, which will provide a sense of control. Avoiding separation
from family during hospitalizations, and helping parents learn special care needs of their child should be
practiced as part of family-centered care. It does not necessarily foster autonomy. Exposing the child to
pleasurable experiences, especially sensory ones, is a supportive intervention. It does not promote autonomy.
PTS: 1 DIF: Cognitive Level: Apply REF: 518
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
12. The feeling of guilt that the child caused the disability or illness is especially critical in which child?
a. Toddler
b. Preschooler
c. School-age child
d. Adolescent
ANS: B
Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or disability or are
being punished for wrongdoings. Toddlers are focused on establishing their autonomy. The illness will foster
dependence. The school-age child will have limited opportunities for achievement and may not be able to
understand limitations. Adolescents face the task of incorporating their disabilities into their changing selfconcept.
PTS: 1 DIF: Cognitive Level: Understand REF: 523
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
13. A 9-year-old boy has several physical disabilities. His father explains to the nurse that his son concentrates
on what he can, rather than cannot, do and is as independent as possible. The nurses best interpretation of this
is that the:
a. father is experiencing denial.
b. father is expressing his own views.
c. child is using an adaptive coping style.
d. child is using a maladaptive coping style.
ANS: C
The father is describing a well-adapted child who has learned to accept physical limitations. These children
function well at home, at school, and with peers. They have an understanding of their disorder that allows them
to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation. The father
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is describing his childs behavior. He is not denying the childs limitations. The father is exhibiting an adaptive
coping style.
PTS: 1 DIF: Cognitive Level: Analyze REF: 510
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
14. The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset
and tearful. The nurse asks, Whom do you talk to when something is worrying you? This should be interpreted
as:
a. inappropriate, because the parent is so upset.
b. a diversion of the present crisis to similar situations with which the parent has dealt.
c. an intervention to find someone to help the parent.
d. part of assessing the parents available support system.
ANS: D
These are important data for the nurse to obtain. This question will provide information about the marital
relationship (whether the parent speaks to the spouse), alternate support systems, and ability to communicate.
By assessing these areas, the nurse can facilitate the identification and use of community resources as needed.
It is an important part of assessment information to determine the parents support network. The nurse is
obtaining information to help support the parent through the diagnosis. The parent is not in need of additional
parenting help at this time.
PTS: 1 DIF: Cognitive Level: Apply REF: 504
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
15. The nurse is providing support to parents at the time their child is diagnosed with chronic disabilities. The
nurse notices that the parents keep asking the same questions. What is the nurses best intervention?
a. Patiently continue to answer questions.
b. Kindly refer them to someone else for answering their questions.
c. Recognize that some parents cannot understand explanations.
d. Suggest that they ask their questions when they are not upset.
ANS: A
Diagnosis is one of the anticipated stress points for parents. The parents may not hear or remember all that is
said to them. The nurse should continue to provide the kind of information they desire. This is a particularly
stressful time for the parents; the nurse can play a key role in providing necessary information. Parents should
be provided with oral and written information. The nurse needs to work with the family to ensure
understanding of the information. The parents require information at the time of diagnosis. Other questions
will arise as they adjust to the information.
PTS: 1 DIF: Cognitive Level: Apply REF: 505
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
16. Which is the most appropriate nursing intervention to promote normalization in a school-age child with a
chronic illness?
a. Give child as much control as possible.
b. Ask childs peer to make child feel normal.
c. Convince child that nothing is wrong with him or her.
d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings.
ANS: A
The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child
should be given as much control as possible. It is unrealistic to expect one individual to make the child feel
normal. The child has a chronic illness. It would be unacceptable to convince the child that nothing is wrong.
The family rules should be similar for each of the children in a family. Resentment and hostility can arise if
different standards are applied to each child.
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PTS: 1 DIF: Cognitive Level: Apply REF: 504
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
17. Nursing interventions to help the siblings of a child with special needs cope include:
a. explaining to the siblings that embarrassment is unhealthy.
b. encouraging the parents not to expect siblings to help them care for the child with special needs.
c. providing information to the siblings about the childs condition only as they request it.
d. suggesting to the parents ways of showing gratitude to the siblings who help care for the child with special
needs.
ANS: D
The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked
to take on additional responsibilities to help the parents to care for the child. The parents should show
gratitude, such as an increase in allowance, special privileges, and verbal praise. Embarrassment may be
associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an
appropriate manner without punishing the sibling. The parents may need assistance with the care of the child.
Most siblings are positive about the extra responsibilities. The siblings need to be informed about the childs
condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is
wrong with the child.
PTS: 1 DIF: Cognitive Level: Apply REF: 506
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
18. The parents of a child born with disabilities ask the nurse for advice about discipline. The nurses response
should be based on knowledge that discipline is:
a. essential for the child.
b. too difficult to implement with a special-needs child.
c. not needed unless child becomes problematic.
d. best achieved with punishment for misbehavior.
ANS: A
Discipline is essential for the child. It provides boundaries on which to test out their behavior and teaches them
socially acceptable behaviors. The nurse should teach the parents ways to manage the childs behavior before it
becomes problematic. Punishment is not effective in managing behavior.
PTS: 1 DIF: Cognitive Level: Understand REF: 518
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
19. Kelly, an 8-year-old girl, will soon be able to return to school after an injury that resulted in several severe,
chronic disabilities. Which is the most appropriate action by the school nurse?
a. Recommend that the childs parents attend school at first to prevent teasing.
b. Prepare the childs classmates and teachers for changes they can expect.
c. Refer the child to a school where the children have chronic disabilities similar to hers.
d. Discuss with the child and her parents the fact that her classmates will not accept her as they did before.
ANS: B
Attendance at school is an important part of normalization for Kelly. The school nurse should prepare teachers
and classmates about her condition, abilities, and special needs. A visit by the parents can be helpful, but
unless the classmates are prepared for the changes, it alone will not prevent teasing. Kellys school experience
should be normalized as much as possible. Children need the opportunity to interact with healthy peers, as well
as to engage in activities with groups or clubs composed of similarly affected persons. Children with special
needs are encouraged to maintain and reestablish relationships with peers and to participate according to their
capabilities.
PTS: 1 DIF: Cognitive Level: Apply REF: 519
TOP: Integrated Process: Nursing Process: Implementation
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MSC: Area of Client Needs: Psychosocial Integrity
20. A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing
doses of his medication. The nurse should explain to his parents that:
a. he needs more discipline.
b. he needs more socialization with peers.
c. this is part of normal adolescence.
d. this is how he is asking for more parental control.
ANS: C
Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence.
PTS: 1 DIF: Cognitive Level: Apply REF: 519
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
21. Which term best describes a multidisciplinary approach to the management of a terminal illness that
focuses on symptom control and support?
a. Dying care
b. Curative care
c. Restorative care
d. Palliative care
ANS: D
This is one of the definitions of palliative care. The goal of palliative care is the achievement of the highest
possible quality of life for patients and their families.
PTS: 1 DIF: Cognitive Level: Understand REF: 520
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
22. Which best describes how preschoolers react to the death of a loved one?
a. Preschooler is too young to have a concept of death.
b. Preschooler may feel guilty and responsible for the death.
c. Grief is acute but does not last long at this age.
d. Grief is usually expressed in the same way in which the adults in the preschoolers life are expressing grief.
ANS: B
Because of egocentricity, the preschooler may feel guilty and responsible for the death.
PTS: 1 DIF: Cognitive Level: Understand REF: 523
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
23. A preschooler is found digging up a pet bird that was recently buried after it died. The best explanation for
this behavior is that:
a. he has a morbid preoccupation with death.
b. he is looking to see whether a ghost took it away.
c. the loss is not yet resolved, and professional counseling is needed.
d. reassurance is needed that the pet has not gone somewhere else.
ANS: D
The preschooler can recognize that the pet has died but has difficulties with the permanence. Digging up the
bird gives reassurance that the bird is still present.
PTS: 1 DIF: Cognitive Level: Understand REF: 523
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
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24. At what age do most children have an adult concept of death as being inevitable, universal, and
irreversible?
a. 4 to 5 years
b. 6 to 8 years
c. 9 to 11 years
d. 12 to 16 years
ANS: C
By age 9 to 11 years, children have an adult concept of death. They realize that it is inevitable, universal, and
irreversible.
PTS: 1 DIF: Cognitive Level: Understand REF: 524
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
25. Which is most descriptive of a school-age childs reaction to death?
a. Is very interested in funerals and burials
b. Has little understanding of words such as forever
c. Imagines the deceased person to be still alive
d. Has an idealistic view of world and criticizes funerals as barbaric
ANS: A
The school-age child is interested in post-death services and may be inquisitive about what happens to the
body.
PTS: 1 DIF: Cognitive Level: Understand REF: 524
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
26. At what developmental period do children have the most difficulty coping with death, particularly if it is
their own?
a. Toddlerhood
b. Preschool
c. School-age
d. Adolescence
ANS: D
Adolescents, because of their mature understanding of death, remnants of guilt and shame, and issues with
deviations from normal, have the most difficulty coping with death.
PTS: 1 DIF: Cognitive Level: Understand REF: 524
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
27. A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from
knowing the seriousness of the illness. The nurse should explain that:
a. this will help the child cope effectively by denial.
b. this attitude is helpful to give parents time to cope.
c. terminally ill children know when they are seriously ill.
d. terminally ill children usually choose not to discuss the seriousness of their illness.
ANS: C
The child needs honest and accurate information about the illness, treatments, and prognosis. Children, even at
a young age, realize that something is seriously wrong and that it involves them. The nurse should help the
parents understand the importance of honesty.
PTS: 1 DIF: Cognitive Level: Analyze REF: 522
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
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28. A cure is no longer possible for a young child with cancer. The nursing staff recognizes that the goal of
treatment must shift from cure to palliation. Which is an important consideration at this time?
a. The family is included in the decision to shift the goals of treatment.
b. The decision must be made by the health professionals involved in the childs care.
c. The family needs to understand that palliative care takes place in the home.
d. The decision should not be communicated to the family because it will encourage a sense of hopelessness.
ANS: A
When the child reaches the terminal stage, the nurse and physician should explore the familys wishes. The
family should help decide what interventions will occur as they plan for their childs death.
PTS: 1 DIF: Cognitive Level: Apply REF: 520
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
29. The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their
child one more time. The nurses most appropriate response is to:
a. grant their request.
b. assess why they feel this is necessary.
c. discourage this because it will only prolong their grief.
d. kindly explain that they need to say good-bye to their child now and leave.
ANS: A
The parents should be allowed to remain with their child after the death. The nurse can remove all the tubes
and equipment and offer the parents the option of preparing the body.
PTS: 1 DIF: Cognitive Level: Apply REF: 529
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
30. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still hear the childs
voice and have trouble sleeping. They describe feeling empty and depressed. The nurse should recognize that:
a. these are normal grief responses.
b. the pain of the loss is usually less by this time.
c. these grief responses are more typical of the early stages of grief.
d. this grieving is essential until the pain is gone and the child is gradually forgotten.
ANS: A
These are normal grief responses. The process of grief work is lengthy.
PTS: 1 DIF: Cognitive Level: Understand REF: 530
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
31. At the time of a childs death, the nurse tells his mother, We will miss him so much. The best interpretation
of this is that the nurse is:
a. pretending to be experiencing grief.
b. expressing personal feelings of loss.
c. denying the mothers sense of loss.
d. talking when listening would be better.
ANS: B
A patients death is one of the most stressful aspects of critical care or oncology nursing. Nurses experience
reactions similar to those of family members because of their involvement with the child and family during the
illness. Nurses often have feelings of personal loss when a patient dies.
PTS: 1 DIF: Cognitive Level: Analyze REF: 531
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
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32. Which is an appropriate nursing intervention when providing comfort and support for a child when death is
imminent?
a. Limit care to essentials.
b. Avoid playing music near child.
c. Explain to child need for constant measurement of vital signs.
d. Whisper to child instead of using normal voice.
ANS: A
When death is imminent, care should be limited to interventions for palliative care.
PTS: 1 DIF: Cognitive Level: Apply REF: 526
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
33. The nurse is providing support to a family who is experiencing anticipatory grief related to their childs
imminent death. Which of the following is an appropriate nursing intervention?
a. Be available to family.
b. Attempt to lighten the mood.
c. Suggest activities to cheer up the family.
d. Discourage crying until actual time of death.
ANS: A
One of the most important nursing interventions of death is the availability of the nurse for the family.
PTS: 1 DIF: Cognitive Level: Apply REF: 528
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
34. The nurse and a new nurse are caring for a child who will require palliative care. Which statement made by
the new nurse would indicate a correct understanding of palliative care?
a. Palliative care serves to hasten death and make the process easier for the family.
b. Palliative care provides pain and symptom management for the child.
c. The goal of palliative care is to place the child in a hospice setting at the end of life.
d. The goal of palliative care is to act as the liaison between the family, child, and other health care
professionals.
ANS: B
One of the goals of palliative care is to provide pain and symptom management.
PTS: 1 DIF: Cognitive Level: Apply REF: 521
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
35. Parents are asking about an early intervention program for their child who has special needs. The nurse
relates that this program is for which age of child?
a. Birth to 1 year of age
b. Birth to 3 years of age
c. Ages 1 to 4
d. Ages 4 and 5
ANS: B
A variety of supplemental programs have been designed in the school system to accommodate special needs,
both at school age and younger, through early intervention, which consists of any sustained and systematic
effort to assist children from birth to age 3 years with disabilities and those who are developmentally
vulnerable.
PTS: 1 DIF: Cognitive Level: Remember REF: 504
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
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36. A nurse is planning palliative care for a child with severe pain. Which should the nurse expect to be
prescribed for pain relief?
a. Opioids as needed
b. Opioids on a regular schedule
c. Distraction and relaxation techniques
d. Nonsteroidal anti-inflammatory drugs
ANS: B
Pain medications, for children in palliative care, should be given on a regular schedule, and extra doses for
breakthrough pain should be available to maintain comfort. Opioid drugs such as morphine should be given for
severe pain, and the dose should be increased as necessary to maintain optimal pain relief. Techniques such as
distraction, relaxation techniques, and guided imagery should be combined with drug therapy to provide the
child and family strategies to control pain. Nonsteroidal anti-inflammatory drugs are not sufficient to manage
severe pain for children in palliative care.
PTS: 1 DIF: Cognitive Level: Apply REF: 527
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. Which describes avoidance behaviors parents may exhibit when learning that their child has a chronic
condition? (Select all that apply.)
a. Refuses to agree to treatment
b. Shares burden of disorder with others
c. Verbalizes possible loss of child
d. Withdraws from outside world
e. Punishes self because of guilt and shame
ANS: A, D, E
A parent who refuses to agree to treatment, withdraws from the outside world, and punishes self because of
guilt and shame is exhibiting avoidance coping behaviors. A parent who shares the burden of disorder with
others and verbalizes possible loss of child is exhibiting approach coping behaviors.
PTS: 1 DIF: Cognitive Level: Analyze REF: 508
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
2. Which are appropriate statements the nurse should make to parents after the death of their child? (Select all
that apply.)
a. We feel so sorry that we couldnt save your child.
b. Your child isnt suffering anymore.
c. I know how you feel.
d. Youre feeling all the pain of losing a child.
e. You are still young enough to have another baby.
ANS: A, D
By saying, We feel so sorry that we couldnt save your child, the nurse is expressing personal feeling of loss or
frustration, which is therapeutic. Stating, Youre feeling all the pain of losing a child, focuses on a feeling,
which is therapeutic. The statement, Your child isnt suffering anymore, is a judgmental statement, which is
nontherapeutic. I know how you feel and Youre still young enough to have another baby are statements that
give artificial consolation and are nontherapeutic.
PTS: 1 DIF: Cognitive Level: Apply REF: 531
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
3. Which are adaptive coping patterns used by children with special needs? (Select all that apply.)
a. Feels different and withdraws
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b. Is irritable, moody, and acts out
c. Seeks support
d. Develops optimism
ANS: C, D
Adaptive coping patterns used by children with special needs include seeking support and developing
optimism. Maladaptive behaviors are seeing themselves as different and withdrawing and becoming irritable,
moody, and beginning to act out.
PTS: 1 DIF: Cognitive Level: Understand REF: 510
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
4. A nurse is caring for a child who is near death. Which physical signs indicate the child is approaching
death? (Select all that apply.)
a. Body feels warm
b. Tactile sensation decreasing
c. Speech becomes rapid
d. Change in respiratory pattern
e. Difficulty swallowing
ANS: B, D, E
Physical signs of approaching death include: tactile sensation beginning to decrease, a change in respiratory
pattern, and difficulty swallowing. Even though there is a sensation of heat the body feels cool, not warm, and
speech becomes slurred, not rapid.
PTS: 1 DIF: Cognitive Level: Understand REF: 529
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
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Chapter 18: Impact of Cognitive or Sensory Impairment on the Child
and Family
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: 532
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
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: 532
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: 532
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
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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: 534
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:
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: 535
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: 535
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
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syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are not frequent congenital anomalies
associated with Down syndrome.
PTS: 1 DIF: Cognitive Level: Understand REF: 536
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: 535
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
9. What is one of the major physical characteristics of the child with Down syndrome?
a. Excessive height
b. Spots on the palms
c. Inflexibility of the joints
d. Hypotonic musculature
ANS: D
Hypotonic musculature is one of the major characteristics. Children with Down syndrome have short stature
and a transverse palmar crease. Hyperflexibility is a characteristic of Down syndrome.
PTS: 1 DIF: Cognitive Level: Understand REF: 536
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 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: 536
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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: 537
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 cool-mist vaporizer will keep the mucous membranes
moist and liquefy secretions. The child has a protruding tongue, which makes feeding difficult. The parents
must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is
predisposed to constipation. Calories should be appropriate to the childs weight and growth needs, not age.
PTS: 1 DIF: Cognitive Level: Apply REF: 538
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
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: 538
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
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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: 540
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 conductivesensorineural, and central auditory imperceptive are less common types of hearing loss.
PTS: 1 DIF: Cognitive Level: Understand REF: 540
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
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: 540
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: 541
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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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: 540
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
19. Which is an implanted ear prosthesis for children with sensorineural hearing loss?
a. Hearing aid
b. Cochlear implant
c. Auditory implant
d. Amplification device
ANS: B
Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have
severe or profound hearing loss of sensorineural origin. Hearing aids and amplification devices are external
devices for enhancing hearing. Auditory implants do not exist.
PTS: 1 DIF: Cognitive Level: Understand REF: 541
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: 542
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 543
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 544
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: 544
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: 545
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
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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: 544
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
26. When assessing the eyes of a neonate, the nurse observes opacity of the lens. This represents which
impairment?
a. Blindness
b. Glaucoma
c. Cataracts
d. Retinoblastoma
ANS: C
A cataract is opacity of the lens of the eye. The child may have visual impairment secondary to the cataract,
but the opacity is a cataract. Glaucoma is increased intraocular pressure. Retinoblastoma is a tumor of the eye.
PTS: 1 DIF: Cognitive Level: Understand REF: 545
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: 546
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: 546
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: 546
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: 549
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: 540
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
32. A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive impairment
(CI) who sustained a minor burn. Which strategy should the nurse use to prepare the child for this procedure?
a. Verbally explain what will be done.
b. Have the child watch a video on dressing changes.
c. Demonstrate a dressing change on a doll.
d. Explain the importance of keeping the burn area clean.
ANS: C
Children with CI have a marked deficit in their ability to discriminate between two or more stimuli because of
difficulty in recognizing the relevance of specific cues. However, these children can learn to discriminate if the
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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: 532
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: 538
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
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: 553
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
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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: 551
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: 537
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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: 550
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
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 543
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
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Chapter 19: Family-Centered Care of the Child During Illness and
Hospitalization
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: 555
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. 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: 555
TOP:Integrated Process: Nursing Process: Diagnosis
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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: 557
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: 557
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: 558
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: 559
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.
b. Jealousy and resentment are common reactions to the illness or hospitalization of a sibling.
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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: 559
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: 570
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: 563
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: 556
TOP:Integrated Process: Nursing Process: Implementation
MSC:Area of Client Needs: Health Promotion and Maintenance
11. Samantha, age 5 years, tells the nurse that she needs a Band-Aid where she had an injection. Which is the
best nursing action?
a. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 565
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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: 563
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.
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: 569
TOP:Integrated Process: Nursing Process: Planning
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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: 560
TOP:Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
15. The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the
wrist during a bicycle accident. Which statement by the adolescent should be expected about separation
anxiety?
a. I wish my parents could spend the night with me while I am in the hospital.
b. I think I would like for my siblings to visit me but not my friends.
c. I hope my friends 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: 557
TOP:Integrated Process: Nursing Process: Planning
MSC:Area of Client Needs: Health Promotion and Maintenance
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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: 564
TOP:Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
17. A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports 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 school-age 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: 564
TOP:Integrated Process: Nursing Process: Planning
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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.
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: 566
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: 566
TOP:Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
20. A nurse in the emergency department is assessing a 5-year-old child with symptoms of pneumonia and a
fever of 102 F. Which intervention can the nurse implement to promote a sense of control for the child?
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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.
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: 573
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: 555
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 is beginning to stabilize. When speaking
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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: 574
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: 567
TOP:Integrated Process: Nursing Process: Planning
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MSC: Area of Client Needs: Psychosocial Integrity
3. A child is being discharged from an ambulatory care center after an inguinal hernia repair. Which discharge
interventions should the nurse implement? (Select all that apply.)
a. Discuss dietary restrictions.
b. Hold any analgesic medications until the child is home.
c. Send a pain scale home with the family.
d. Suggest the parents fill the prescriptions on the way home.
e. Discuss complications that may occur.
ANS: A, C, E
The discharge interventions a nurse should implement when a child is being discharged from an ambulatory
care center should include dietary restrictions, being very specific and giving examples of clear fluids or what
is meant by a full liquid diet. The nurse should give specific information on pain control and send a pain scale
home with the family. All complications that may occur after an inguinal hernia repair should be discussed
with the parents. The pain medication, as prescribed, should be given before the child leaves the building and
prescriptions should be filled and given to the family before discharge.
PTS: 1 DIF: Cognitive Level: Apply REF: 572
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: 575
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 562
TOP:Integrated Process: Nursing Process: Assessment
MSC:Area of Client Needs: Health Promotion and Maintenance
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Chapter 20: Pediatric Variations of Nursing Interventions
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: 576
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: 579
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:
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: 579
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.
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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: 579
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: 578
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.
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: 581
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: 585
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. The nurse is caring for an unconscious child. Skin care should include which action?
a. Avoid use of pressure reduction on bed.
b. Massage reddened bony prominences to prevent deep tissue damage.
c. Use draw sheet to move child in bed to reduce friction and shearing injuries.
d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.
ANS: C
A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing
injuries. Do not drag the child from under the arms. Pressure-reduction devices should be used to redistribute
weight. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressurereduction 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: 588
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.
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: 589
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: 590
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.
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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: 590
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.
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: 590
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: 591
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 605
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
15. The nurse wore gloves during a dressing change. 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: 594
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: 594
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 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: 605
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.
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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: 596
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: 581
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
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: 581
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
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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: 599
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: 600
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. The Allen test is performed as a precautionary measure before which procedure?
a. Heel stick
b. Venipuncture
c. Arterial puncture
d. Lumbar puncture
ANS: C
The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial puncture. The
Allen test is used before arterial punctures, not heel sticks, venipunctures, or lumbar punctures.
PTS: 1 DIF: Cognitive Level: Understand REF: 602
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: 602
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
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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: 602
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
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: 604
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: 606
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.
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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: 606
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29. Which is the preferred site for intramuscular injections in infants?
a. Deltoid
b. Dorsogluteal
c. Rectus femoris
d. Vastus lateralis
ANS: D
The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older
children and adults. The rectus femoris is not a recommended site.
PTS: 1 DIF: Cognitive Level: Understand REF: 607
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
30. Guidelines for intramuscular administration of medication in school-age children include which action?
a. Inject medication as rapidly as possible.
b. Insert needle quickly, using a 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: 611
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: 615
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: 619
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: 622
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: 623
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.
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 627
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: 629
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-yearold 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: 629
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.
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: 631
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.
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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: 640
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: 641
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
41. In preparing to give enemas until clear to a young child, the nurse should select which solution?
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: 641
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.
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PTS: 1 DIF: Cognitive Level: Analyze REF: 580
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,
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: 607
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: 594
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: 605
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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.
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: 605
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: 621
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
PTS: 1 DIF: Cognitive Level: Remember REF: 637
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MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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Chapter 21: The Child with Respiratory Dysfunction
MULTIPLE CHOICE
1. The nurse is teaching nursing students about normal physiologic changes in the respiratory system of
toddlers. Which best describes why toddlers have fewer respiratory tract infections as they grow older?
a. The amount of lymphoid tissue decreases.
b. Repeated exposure to organisms causes increased immunity.
c. Viral organisms are less prevalent in the population.
d. Secondary infections rarely occur after viral illnesses.
ANS: B
Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as
children grow older. Viral organisms are not less prevalent, but older children have the ability to resist
invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and group A
b-hemolytic streptococcal infections.
PTS: 1 DIF: Cognitive Level: Understand REF: 637
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: 639
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which explains why cool-mist vaporizers rather than steam vaporizers are recommended in home treatment
of childhood respiratory tract infections?
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: 638
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.
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ANS: A
Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for more than 3 days
to avoid rebound congestion. Drops should be discarded after one illness because they may become
contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops
administered before feedings are more helpful.
PTS: 1 DIF: Cognitive Level: Apply REF: 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
5. Which is an appropriate nursing intervention when caring for an infant with an upper respiratory tract
infection and elevated temperature?
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: 640
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the
infant displays which clinical manifestation?
a. Fussiness
b. Coughing
c. A fever over 99 F
d. Signs of an earache
ANS: D
If an infant with nasopharyngitis shows signs of an earache, it may mean a secondary bacterial infection is
present and the infant should be referred to a practitioner for evaluation. Irritability is common in an infant
with a viral illness. Cough can be a sign of nasopharyngitis. Fever is common in viral illnesses.
PTS: 1 DIF: Cognitive Level: Apply REF: 644
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: 645
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?
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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: 647
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: 648
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: 649
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
11. An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is
prescribed. Which statement made by the parent indicates a correct understanding of the instructions?
a. I should administer all the prescribed medication.
b. I should continue medication until the symptoms subside.
c. I will immediately stop giving medication if I notice a change in hearing.
d. I will stop giving medication if fever is still present in 24 hours.
ANS: A
Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria.
Symptoms may subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics
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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: 648
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: 649
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: 651
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: 651
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.
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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: 653
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: 653
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. Which frequency is recommended for childhood skin testing for tuberculosis (TB) using the Mantoux test?
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: 659
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: 660
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
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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: 662
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.
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: 664
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: 665
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 667
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
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: 667
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: 668
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: 669
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.
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ANS: B
b-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute exacerbations. These
medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce
inflammation in the lungs.
PTS: 1 DIF: Cognitive Level: Understand REF: 670
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: 670
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: 671
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 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: 677
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
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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. Foulsmelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF.
PTS: 1 DIF: Cognitive Level: Understand REF: 677
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 678
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 679
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.
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PTS: 1 DIF: Cognitive Level: Apply REF: 680
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: 680
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 681
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
36. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind?
a. Diet should be high in carbohydrates and protein.
b. Diet should be high in easily digested carbohydrates and fats.
c. Most fruits and vegetables are not well tolerated.
d. Fats and proteins must be greatly curtailed.
ANS: A
Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal
absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A wellbalanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a wellbalanced diet.
PTS: 1 DIF: Cognitive Level: Understand REF: 681
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
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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: 687
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 688
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
39. Effective lone-rescuer CPR on a 5-year-old child should include
a. two breaths to every 30 chest compressions.
b. two breaths to every 15 chest compressions.
c. reassessment of 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 688
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 689
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
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 684
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 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 674
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 673
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 high-prevalence (TB) regions of the world are positive when the
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induration is 10 mm. Children 4 years of age or older without any risk factors are positive when the induration
is 20 mm.
PTS: 1 DIF: Cognitive Level: Understand REF: 659
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
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 656
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 653
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which action
should the nurse include in the 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 645
TOP: Integrated Process: Nursing Process: Implementation
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MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A chest tube has
been inserted to promote continuous closed chest drainage. Which interventions should the nurse implement
when caring for this child? (Select all that apply.)
a. Positioning child on the right side
b. Assessing the chest tube and drainage device for correct settings
c. Administering prescribed doses of analgesia
d. Clamping the chest tube when child ambulates
e. Monitoring for need of supplemental oxygen
ANS: B, C, E
Nursing care of the child with a chest tube requires close attention to respiratory status; the chest tube and
drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is
correct, tubing is free of kinks, dressing covering chest tube insertion site is intact, water seal is maintained,
and chest tube remains in place). Movement in bed and ambulation with a chest tube are encouraged according
to the 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 658
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
SHORT ANSWER
1. A nurse is interpreting the results of a 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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 668
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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.
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
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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Chapter 22: The Child with Gastrointestinal Dysfunction
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: 690
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 719
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: 694
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which
type of dehydration is this infant experiencing?
a. Isotonic
b. Isosmotic
c. Hypotonic
d. Hypertonic
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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: 694
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. An infant is brought to the emergency department with dehydration. Which physical assessment finding
does the nurse expect?
a. 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: 694
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should
further ask the parents if the toddler has which associated factor that is causing the acute diarrhea?
a. Celiac disease
b. Antibiotic therapy
c. Immunodeficiency
d. Protein malnutrition
ANS: B
Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated
with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if
not identified and managed appropriately. Immunodeficiency would occur with chronic diarrhea. Protein
malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection.
PTS: 1 DIF: Cognitive Level: Apply REF: 699
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: 699
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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: 702
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen confirm this
diagnosis?
a. Eosinophils
b. Occult blood
c. pH less than 6
d. Neutrophils and red blood cells
ANS: D
Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance and parasitic
infections are suspected in the presence of eosinophils. Occult blood may indicate pathogens such as Shigella,
Campylobacter, or hemorrhagic Escherichia coli strains. A pH of less than 6 may indicate carbohydrate
malabsorption or secondary lactase insufficiency.
PTS: 1 DIF: Cognitive Level: Understand REF: 702
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: 702
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
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mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates.
PTS: 1 DIF: Cognitive Level: Apply REF: 702
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:
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: 703
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: 704
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: 705
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: 706
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, highcalorie, 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: 708
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: 708
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be
necessary. The nurse should recognize that preparing this child psychologically is:
a. not necessary because of 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
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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: 708
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: 709
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications.
Which should the nurse suggest to minimize reflux?
a. Place in Trendelenburg position after eating.
b. Thicken formula with rice cereal.
c. Give continuous nasogastric tube feedings.
d. Give larger, less frequent feedings.
ANS: B
Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of
formula 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: 710
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
21. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an
infant with GER. 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: 710
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?
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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: 712
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: 713
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.
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: 714
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%
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to 4% of the general population. The standard therapy is surgical removal of the diverticulum.
PTS: 1 DIF: Cognitive Level: Apply REF: 715
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: 716
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. Which is used to treat moderate to severe inflammatory bowel disease?
a. Antacids
b. Antibiotics
c. Corticosteroids
d. Antidiarrheal medications
ANS: C
Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory
response in inflammatory bowel disease. Antacids and antidiarrheal medications are not drugs of choice in the
treatment of inflammatory bowel disease. Antibiotics may be used as an adjunctive therapy to treat
complications.
PTS: 1 DIF: Cognitive Level: Understand REF: 717
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: 720
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.
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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: 722
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30. Which vaccine is now recommended for the immunization of all newborns?
a. Hepatitis A vaccine
b. Hepatitis B vaccine
c. Hepatitis C vaccine
d. Hepatitis A, B, and C vaccines
ANS: B
Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for
hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only
hepatitis B vaccine is recommended for newborns.
PTS: 1 DIF: Cognitive Level: Understand REF: 724
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: 725
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: 725
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 727
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: 728
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: 728
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: 729
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: 729
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 730
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
39. Which type of hernia has an impaired blood supply to the herniated organ?
a. Hiatal hernia
b. Incarcerated hernia
c. Omphalocele
d. Strangulated hernia
ANS: D
A strangulated hernia is one in which the blood supply to the herniated organ is impaired. Hiatal hernia is the
intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. Incarcerated hernia is
a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base
of the umbilical cord. The sac is covered with peritoneum, not skin.
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PTS: 1 DIF: Cognitive Level: Understand REF: 732
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 732
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: 733
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
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: 735
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
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and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
PTS: 1 DIF: Cognitive Level: Understand REF: 735
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: 736
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
45. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while
waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which
nursing action is the most appropriate?
a. Notify practitioner.
b. Measure abdominal girth.
c. Auscultate for bowel sounds.
d. Take vital signs, including blood pressure.
ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately
reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action
would be to report the normal stool to the practitioner.
PTS: 1 DIF: Cognitive Level: Apply REF: 736
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: 741
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.
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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: 742
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
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: 734
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: 720
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
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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: 711
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. A child who has just had definitive repair of a high rectal malformation is to be discharged. Which should
the nurse address in the discharge preparation of this family? (Select all that apply.)
a. Perineal and wound care
b. Necessity of firm stools to keep suture line clean
c. Bowel training beginning as soon as child returns home
d. Reporting any changes in stooling patterns to practitioner
e. Use of diet modification to prevent constipation
ANS: A, D, E
Wound care instruction is necessary in a child who is being discharged after surgery. The parents are taught to
notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided,
since a firm stool will place strain on the suture line. Fiber and stool softeners are often given to keep stools
soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel
training may begin, depending on the childs developmental and physiologic readiness.
PTS: 1 DIF: Cognitive Level: Apply REF: 739
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: 722
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
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b. Feedings through a gastrostomy tube
c. Nasogastric tube to continuous low wall suction
d. Suctioning with a Replogle tube passed orally to the end of the pouch
e. Gastrostomy tube to gravity drainage
ANS: A, D, E
The most desirable position for a newborn who has TEF is supine (or sometimes prone) with the head elevated
on an inclined plane of at least 30 degrees. This positioning minimizes the reflux of gastric secretions at the
distal esophagus into the trachea and bronchi, especially when 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: 731
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: 736
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: 707
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
SHORT ANSWER
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 702
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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Chapter 23: The Child with Cardiovascular Dysfunction
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 754
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be
assessing for?
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 772
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 741
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which explanation regarding cardiac catheterization is appropriate for a preschool child?
a. Postural drainage will be performed every 4 to 6 hours after the test.
b. It is necessary to be completely asleep during the test.
c. The test is short, usually taking less than 1 hour.
d. When the procedure is done, you will have to keep your leg straight for at least 4 hours.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 742
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse
that the bandage is too wet. The nurse finds the bandage and bed soaked with blood. 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 742
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the
adolescent would indicate a need for further teaching?
a. I should avoid tub baths but may shower.
b. I have to stay on strict bed rest for 3 days.
c. I should remove the pressure dressing the day after the procedure.
d. I may attend school but should avoid exercise for several days.
ANS: B
The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a
tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive
bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to
school.
PTS: 1 DIF: Cognitive Level: Analyze REF: 742
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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 lower-pressure 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
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directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of
oxygenated blood to the lungs.
PTS: 1 DIF: Cognitive Level: Analyze REF: 744
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher
pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic
stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary
blood flow. Transposition of the great arteries results in mixed blood flow.
PTS: 1 DIF: Cognitive Level: Understand REF: 744
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes
tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta,
and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right
ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot
has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic
hypertrophy.
PTS: 1 DIF: Cognitive Level: Understand REF: 749
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in
decreased pulmonary blood flow?
a. Atrial septal defect
b. Tetralogy of Fallot
c. Ventricular septal defect
d. Patent ductus arteriosus
ANS: B
Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure
in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and
ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.
PTS: 1 DIF: Cognitive Level: Understand REF: 749
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?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 749
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities
ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion.
Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical
manifestations of impaired myocardial function.
PTS: 1 DIF: Cognitive Level: Understand REF: 754
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 754
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.
PTS: 1 DIF: Cognitive Level: Remember REF: 754
TOP: Integrated Process: Nursing Process: Implementation
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MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral 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 below 90 to 110 beats/min is the determination for
not giving a digoxin dose to infants and young children.
PTS: 1 DIF: Cognitive Level: Apply REF: 755
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: 755
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: 758
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
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very small. Specific guidelines are available for parents to learn how to administer the drug safely and to
monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Small
amounts of the liquid are given to infants, making it easy to overmedicate or undermedicate. Parents may lack
the necessary expertise to administer the drug at first, but with discharge preparation, they should be prepared
to administer the drug safely.
PTS: 1 DIF: Cognitive Level: Apply REF: 758
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: 757
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: 759
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.
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: 760
TOP: Integrated Process: Nursing Process: Implementation
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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: 760
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: 762
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
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: 764
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
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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: 765
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: 765
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.
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: 765
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. Short-acting 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: 765
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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: 767
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
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: 767
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: 767
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
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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.
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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
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: 769
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: 768
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: 768
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
36. When discussing hyperlipidemia with a group of adolescents, the nurse should explain that cardiovascular
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disease can be prevented by high levels of:
a. cholesterol.
b. triglycerides.
c. low-density lipoproteins (LDLs).
d. high-density lipoproteins (HDLs).
ANS: D
HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins.
It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs are not
protective against cardiovascular disease.
PTS: 1 DIF: Cognitive Level: Apply REF: 770
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: 775
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
38. When caring for the child with Kawasaki disease, the nurse should know which information?
a. A 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: 778
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: 779
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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: 781
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: 780
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: 783
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
43. A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While
an airway is being established, the nurse should prepare which medication for immediate administration?
a. Diphenhydramine (Benadryl)
b. Dobutamine (Dobutarex)
c. Epinephrine (Adrenalin)
d. Calcium chloride (calcium chloride)
ANS: C
After the first priority of establishing an airway, administration of epinephrine is the drug of choice.
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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: 781
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: 783
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
45. A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the
child during the procedure. The nurse should answer with which response?
a. You will be able to hold your child during the procedure.
b. Your child can be active during the procedure, but 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: 740
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
46. The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which
intervention to decrease cardiac demands?
a. Organize nursing activities to allow for uninterrupted sleep.
b. Allow the infant to sleep through feedings during the night.
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: 758
TOP: Integrated Process: Nursing Process: Implementation
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47. The nurse is admitting a child with coarctation of the aorta. Which figure depicts this congenital heart
defect?
a. c.
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Chapter 24: The Child with Hematologic or Immunologic Dysfunction
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 787
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for
this child?
a. Game of hide and seek in the 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 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 789
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is teaching parents about the importance of iron in a toddlers diet. Which explains why iron
deficiency anemia is common during toddlerhood?
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 790
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 790
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.
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 791
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.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 791
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. Parents of a child with sickle cell anemia ask the nurse, What happens to the hemoglobin in sickle cell
anemia? Which statement by the nurse explains the disease process?
a. Normal adult hemoglobin is replaced by abnormal hemoglobin.
b. There is a lack of cellular hemoglobin being produced.
c. There is a deficiency in the production of globulin chains.
d. The size and depth of the hemoglobin are affected.
ANS: A
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult
hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being
produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in
production of certain globulin chains. Iron deficiency anemia affects the size and depth of the color.
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TOP: Integrated Process: Teaching/Learning
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 792
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 792
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an
acute vasoocclusive crisis?
a. Circulatory collapse
b. Cardiomegaly, systolic murmurs
c. Hepatomegaly, intrahepatic cholestasis
d. Painful swelling of hands and feet; painful joints
ANS: D
A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful
swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen;
and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises.
Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive
phenomena.
PTS: 1 DIF: Cognitive Level: Understand REF: 792
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 794
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.
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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.
PTS: 1 DIF: Cognitive Level: Apply REF: 793
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 797
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 799
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. Chelation therapy is begun on a child with b-thalassemia major. 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 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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PTS: 1 DIF: Cognitive Level: Understand REF: 800
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 800
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 801
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 blood-clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become 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 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.
PTS: 1 DIF: Cognitive Level: Understand REF: 801
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse is conducting a staff in-service on childhood blood disorders. Which describes the pathology of
idiopathic thrombocytopenic purpura?
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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 804
TOP: Integrated Process: Teaching/Learning
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 807
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
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 807
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 808
TOP: Integrated Process: Nursing Process: Planning
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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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 807
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 817
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: 808
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
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vaccines.
PTS: 1 DIF: Cognitive Level: Apply REF: 808
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 808
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 809
TOP: Integrated Process: Nursing Process: Implementation
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: 809
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.
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b. Firmly insist that child eat normally.
c. Begin gavage feedings to supplement diet.
d. Serve foods that are either hot or cold.
ANS: A
A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should
relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or
bicarbonate mouthwashes; and local anesthetics. The stomatitis is a temporary condition. The child can resume
good food habits as soon as the condition resolves.
PTS: 1 DIF: Cognitive Level: Apply REF: 810
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: 810
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: 811
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: 813
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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: 813
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: 814
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: 814
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
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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: 815
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: 815
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: 815
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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: 816
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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: 801
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: 806
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which
interventions should the nurse plan to implement for this child? (Select all that apply.)
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
aspirin-containing compound should be used. Acetaminophen is a suitable aspirin substitute, especially for
controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums.
Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing
clotting factor. The products available are factor VIII concentrates.
PTS: 1 DIF: Cognitive Level: Apply REF: 803
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
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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: 803
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.
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: 796
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: 810
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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
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: 808
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.
PTS: 1 DIF: Cognitive Level: Apply REF: 817
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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Chapter 25: The Child with Cancer
MULTIPLE CHOICE
1. What childhood cancer may demonstrate patterns of inheritance that suggest a familial basis?
a.
Leukemia
b.
Retinoblastoma
c.
Rhabdomyosarcoma
d.
Osteogenic sarcoma
ANS: B
Retinoblastoma is an example of a pediatric cancer that demonstrates inheritance. The absence of the
retinoblastoma gene allows for abnormal cell growth and the development of retinoblastoma. Chromosome
abnormalities are present in many malignancies. They do not indicate a familial pattern of inheritance. The
Philadelphia chromosome is observed in almost all individuals with chronic myelogenous leukemia. There is
no evidence of a familial pattern of inheritance for rhabdomyosarcoma or osteogenic sarcoma cancers.
DIF: Cognitive Level: Understanding REF: 815
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. As part of the diagnostic evaluation of a child with cancer, biopsies are important for staging. What
statement explains what staging means?
a.
Extent of the disease at the time of diagnosis
b.
Rate normal cells are being replaced by cancer cells
c.
Biologic characteristics of the tumor or lymph nodes
d.
Abnormal, unrestricted growth of cancer cells producing organ damage
ANS: A
Staging is a description of the extent of the disease at the time of diagnosis. Staging criteria exist for most
tumors. The stage usually relates directly to the prognosis; the higher the stage, the poorer the prognosis. The
rate that normal cells are being replaced by cancer cells is not a definition of staging. Classification of the
tumor refers to the biologic characteristics of the tumor or lymph nodes. Abnormal, unrestricted growth of
cancer cells producing organ damage describes how cancer cells grow and can cause damage to an organ.
DIF: Cognitive Level: Understanding REF: 828TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
3. What statement related to clinical trials developed for pediatric cancers is most accurate?
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a.
Are accessible only in major pediatric centers
b.
Do not require consent for standard therapy
c.
Provide the best available therapy compared with an expected improvement
d.
Are standardized to provide the same treatment to all children with the disease
330
ANS: C
Most clinical trials have a control group in which the patients receive the best available therapy currently
known. The experimental group(s) receives treatment that is thought to be even better. The protocol outlines
the therapy plan. Protocols are developed for many pediatric cancers. They can be accessed by pediatric
oncologists throughout the United States. Consent is always required in treatment of children, especially for
research protocols. The protocol is designed to optimize therapy for children based on disease type and stage.
DIF: Cognitive Level: Understanding REF: 817TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
4. Chemotherapeutic agents are classified according to what feature?
a.
Side effects
b.
Effectiveness
c.
Mechanism of action
d.
Route of administration
ANS: C
Chemotherapeutic agents are classified according to mechanism of action. For example, antimetabolites
resemble essential metabolic elements needed for growth but are different enough to block further
deoxyribonucleic acid (DNA) synthesis. Although the side effect profiles may be similar for drugs within a
classification, they are not the basis for classification. Most chemotherapeutic regimens contain combinations
of drugs. The effectiveness of any one drug is relative to the cancer type, combination therapy, and protocol for
administration. The route of administration is determined by the pharmacodynamics and pharmacokinetics of
each drug.
DIF: Cognitive Level: Understanding REF: 817
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. What type of chemotherapeutic agent alters the function of cells by replacing a hydrogen atom of a
molecule?
a.
Plant alkaloids
b.
Antimetabolites
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c.
Alkylating agents
d.
Antitumor antibiotics
331
ANS: C
Alkylating agents replace a hydrogen atom with an alkyl group. The irreversible combination of alkyl groups
with nucleotide chains, particularly deoxyribonucleic acid (DNA), causes unbalanced growth of unaffected cell
constituents so that the cell eventually dies. Plant alkaloids arrest the cell in metaphase by binding to proteins
needed for spindle formation. Antimetabolites resemble essential metabolic elements needed for growth but
are different enough to block further DNA synthesis. Antitumor antibiotics are natural substances that interfere
with cell division by reacting with DNA in such a way as to prevent further replication of DNA and
transcription of ribonucleic acid (RNA).
DIF: Cognitive Level: Understanding REF: 817
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. What side effect commonly occurs with corticosteroid (prednisone) therapy?
a.
Alopecia
b.
Anorexia
c.
Nausea and vomiting
d.
Susceptibility to infection
ANS: D
Corticosteroids have immunosuppressive effects. Children who are taking prednisone are susceptible to
infections. Hair loss is not a side effect of corticosteroid therapy. Children taking corticosteroids have
increased appetites. Gastric irritation, not nausea and vomiting, is a potential side effect. The medicine should
be given with food.
DIF: Cognitive Level: Understanding REF: 831
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. What chemotherapeutic agent is classified as an antitumor antibiotic?
a.
Cisplatin (Platinol AQ)
b.
Vincristine (Oncovin)
c.
Methotrexate (Texall)
d.
Daunorubicin (Cerubidine)
ANS: D
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Daunorubicin is an antitumor antibiotic. Cisplatin is classified as an alkylating agent. Vincristine is a plant
alkaloid. Methotrexate is an antimetabolite.
DIF: Cognitive Level: Understanding REF: 817
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child
suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate?
a.
Recheck the rate of drug infusion.
b.
Stop the drug infusion immediately.
c.
Observe the child closely for next 10 minutes.
d.
Explain to the child that this is an expected side effect.
ANS: B
When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be
withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to
minimize the amount of drug that infuses. The infusion rate can be confirmed at a later time. Observation of
the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an
allergic reaction, not an expected response.
DIF: Cognitive Level: Applying REF: 818
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
9. Total-body irradiation is indicated for what reason?
a.
Palliative care
b.
Lymphoma therapy
c.
Definitive therapy for leukemia
d.
Preparation for bone marrow transplant
ANS: D
Total-body irradiation is used as part of the destruction of the childs immune system necessary for a bone
marrow transplant. The child is at great risk for complications because there is no supportive therapy until
engraftment of the donor marrow takes place. Irradiation for palliative care is done selectively. The area that is
causing pain or potential obstruction is irradiated. Lymphoma and leukemia are treated through a combination
of modalities. Total-body irradiation is not indicated.
DIF: Cognitive Level: Understanding REF: 818
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
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10. The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary.
What information should the nurse recognize as important when discussing this with the family?
a.
BMT should be done at the time of diagnosis.
b.
Parents and siblings of the child have a 25% chance of being a suitable donor.
c.
If BMT fails, chemotherapy or radiotherapy will need to be continued.
d.
Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA)
system.
ANS: D
The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the
disease process involved. It usually follows intensive high-dose chemotherapy or radiotherapy. Usually,
parents only share approximately 50% of the genetic material with their children. A one in four chance exists
that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. The
decision to continue chemotherapy or radiotherapy if BMT fails is not appropriate to discuss with the parents
when planning the BMT. That decision will be made later.
DIF: Cognitive Level: Applying REF: 819
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
11. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone
marrow will be administered by which method?
a.
Bone grafting
b.
Intravenous infusion
c.
Bone marrow injection
d.
Intraabdominal infusion
ANS: B
Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the recipients
marrow and repopulate it.
DIF: Cognitive Level: Applying REF: 819
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
12. After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis
syndrome includes which therapeutic intervention?
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a.
Hydration
b.
Oxygenation
c.
Corticosteroids
d.
Pain management
334
ANS: A
Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial treatment of
leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used
to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor
lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain
management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis
syndrome.
DIF: Cognitive Level: Analyzing REF: 820TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
13. Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include
which therapeutic intervention?
a.
Restrict oral fluids.
b.
Institute strict isolation.
c.
Use good hand-washing technique.
d.
Give immunizations appropriate for age.
ANS: C
Good hand washing minimizes the exposure to infectious organisms and decreases the chance of infection
spread. Oral fluids are encouraged if the child is able to drink. If possible, the intravenous route is not used
because of the increased risk of infection from parenteral fluid administration. Strict isolation is not indicated.
When the child is immunocompromised, the vaccines are not effective. If necessary, the appropriate
immunoglobulin is administered.
DIF: Cognitive Level: Applying REF: 824
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
14. In teaching parents how to minimize or prevent bleeding episodes when the child is myelosuppressed, the
nurse includes what information?
a.
Meticulous mouth care is essential to avoid mucositis.
b.
Rectal temperatures are necessary to monitor for infection.
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c.
Intramuscular injections are preferred to intravenous ones.
d.
Platelet transfusions are given to maintain a count greater than 50,000/mm3.
335
ANS: A
The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in
bleeding. The child and family are taught how to perform good oral hygiene to minimize gingival bleeding and
mucositis. Rectal temperatures are avoided to minimize the risk of ulceration. Hygiene is also emphasized.
Intramuscular injections are avoided because of the risk of bleeding into the muscle and of infection. Platelet
transfusions are usually not given unless there is active bleeding or the platelet count is less than 10,000/mm3.
The use of platelets when not necessary can contribute to antibody formation and increased destruction of
platelets when transfused.
DIF: Cognitive Level: Applying REF: 823TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
15. A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy
for the first time. What is the most appropriate nursing action to prevent or minimize these reactions with
subsequent treatments?
a.
Administer the chemotherapy between meals.
b.
Give an antiemetic before chemotherapy begins.
c.
Have the child bring favorite foods for snacks.
d.
Keep the child NPO (nothing by mouth) until nausea and vomiting subside.
ANS: B
The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer a
5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the chemotherapy is begun. The goal is
to prevent anticipatory signs and symptoms. The child will experience nausea with chemotherapy whether or
not food is present in the stomach. Because some children develop aversions to foods eaten during
chemotherapy, refraining from offering favorite foods is advised. Keeping the child NPO until nausea and
vomiting subside will help with this episode, but the child will have discomfort and be at risk for dehydration.
DIF: Cognitive Level: Applying REF: 824
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
16. A young child with leukemia has anorexia and severe stomatitis. What approach should the nurse suggest
that the parents try?
a.
Relax any eating pressures.
b.
Firmly insist that the child eat normally.
c.
Serve foods that are either hot or cold.
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d.
336
Provide only liquids because chewing is painful.
ANS: A
A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should
relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or
bicarbonate mouthwashes; and local anesthetics. Insisting that the child eat normally is not suggested. For
some children, not eating may be a way to maintain some control. This can set the child and caregiver in
opposition to each other. Hot and cold foods can be painful on ulcerated mucosal membranes. Substitution of
high-calorie foods that the child likes and can eat should be used.
DIF: Cognitive Level: Applying REF: 824
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
17. The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse
include?
a.
Wearing hats or scarves is preferable to a wig.
b.
Expose head to sunlight to stimulate hair regrowth.
c.
Hair may have a slightly different color or texture when it regrows.
d.
Regrowth of hair usually begins 12 months after chemotherapy ends.
ANS: C
Alopecia is a side effect of certain chemotherapeutic agents and cranial irradiation. When the hair regrows, it
may be of a different color or texture. Children should choose the head covering they prefer. A wig should be
selected similar to the childs own hairstyle and color before the hair loss. The head should be protected from
sunlight to avoid sunburn. The hair usually grows back within 3 to 6 months after the cessation of treatment.
DIF: Cognitive Level: Applying REF: 825
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
18. What pain management approach is most effective for a child who is having a bone marrow test?
a.
Relaxation techniques
b.
Administration of an opioid
c.
EMLA cream applied over site
d.
Conscious or unconscious sedation
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ANS: D
Children need explanations before each procedure that is being done to them. 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 sedation.
DIF: Cognitive Level: Applying REF: 826TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
19. The nurse is caring for a child receiving chemotherapy for leukemia. The childs granulocyte count is
600/mm3 and platelet count is 45,000/mm3. What oral care should the nurse recommend for this child?
a.
Rinsing mouth with water
b.
Daily toothbrushing and flossing
c.
Lemon glycerin swabs for cleansing
d.
Wiping teeth with moistened gauze or Toothettes
ANS: B
Oral care is essential for children receiving chemotherapy to prevent infections and other complications. When
the childs granulocyte count is above 500/mm3 and platelet count is above 40,000/mm3, daily brushing and
flossing are recommended. Rinsing the mouth with water is not effective for oral hygiene. Lemon glycerin
swabs are avoided because they have a drying effect on the mucous membranes, and the lemon may irritate
eroded tissue and decay the childs teeth. Wiping teeth with moistened gauze or Toothettes is recommended
when the childs granulocyte count is below 500/mm3 and platelet count is below 40,000/mm3.
DIF: Cognitive Level: Applying REF: 826TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
20. What 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, mumps, rubella (MMR)
ANS: D
The vaccine used for MMR is a live virus and can cause serious disease in immunocompromised children. The
tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and can be given to
immunosuppressed children. The immune response is likely to be suboptimum, so delaying vaccination is
usually recommended.
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DIF: Cognitive Level: Analyzing REF: 826
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
21. What description identifies the pathophysiology of leukemia?
a.
Increased blood viscosity
b.
Abnormal stimulation of the first stage of coagulation process
c.
Unrestricted proliferation of immature white blood cells (WBCs)
d.
Thrombocytopenia from an excessive destruction of platelets
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 result secondary to the increased number of WBCs. The coagulation process is unaffected by
leukemia. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.
DIF: Cognitive Level: Understanding REF: 828
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. A child with leukemia is receiving intrathecal chemotherapy to prevent which condition?
a.
Infection
b.
Brain tumor
c.
Central nervous system (CNS) disease
d.
Drug side effects
ANS: C
Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS prophylactic therapy is
indicated. Intrathecal chemotherapy does not prevent infection or drug side effects. A brain tumor in a child
with leukemia would be a second tumor, and additional appropriate therapy would be indicated.
DIF: Cognitive Level: Applying REF: 829TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
23. A parent tells the nurse that 80% of children with the same type of leukemia as his sons have a 5-year
survival. He believes that because another child on the same protocol as his son has just died, his son now has
a better chance of success. What is the best response by the nurse?
a.
It is sad for the other family but good news for your child.
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b.
Each child has an 80% likelihood of 5-year survival.
c.
The data suggest that 20% of the children in the clinic will die. There are still many hurdles for
your son.
d.
You should avoid the grieving family because you will be benefiting from their loss.
339
ANS: B
This is a common misconception for parents. The success data are based on numerous factors, including the
effectiveness of the protocol and the childs response. These are aggregate data that apply to each child and do
not depend on the success or failure in other children. The failure of one child in a protocol does not improve
the success rate for other children. Although the son does face more hurdles, these are aggregate data, not
specific to the clinic. It may be difficult for this family to be supportive given their concerns about their child.
Families usually form support groups in pediatric oncology settings, and support during bereavement is
common.
DIF: Cognitive Level: Applying REF: 842
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
24. What is a common clinical manifestation of Hodgkin disease?
a.
Petechiae
b.
Bone and joint pain
c.
Painful, enlarged lymph nodes
d.
Nontender enlargement of lymph nodes
ANS: D
Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of
Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin
disease. The enlarged nodes are rarely painful.
DIF: Cognitive Level: Understanding REF: 830
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
25. What are the most common clinical manifestations of brain tumors in children?
a.
Headaches and vomiting
b.
Blurred vision and ataxia
c.
Hydrocephalus and clumsy gait
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d.
340
Fever and poor fine motor control
ANS: A
Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical
manifestations of brain tumors in children. Diplopia (double vision), not blurred vision, can be a presenting
sign of brainstem glioma. Ataxia is a clinical manifestation of brain tumors, but headaches and vomiting are
the most common. Hydrocephalus can be a presenting sign in infants when the sutures have not closed.
Children at this age are usually not walking steadily. Poor fine motor coordination may be a presenting sign of
astrocytoma, but headaches and vomiting are the most common presenting signs of brain tumors.
DIF: Cognitive Level: Understanding REF: 832
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
26. A 5-year-old child is being prepared for surgery to remove a brain tumor. Preparation for surgery should be
based on which information?
a.
Removal of the tumor will stop the various signs and symptoms.
b.
Usually the postoperative dressing covers the entire scalp.
c.
He is not old enough to be concerned about his head being shaved.
d.
He is not old enough to understand the significance of the brain.
ANS: B
The child should be told what he will look and feel like after surgery. This includes the anticipated 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 removal of the tumor, but postsurgical headaches and cerebellar symptoms
such as ataxia may be aggravated. Children should be prepared for the loss of their hair, and it should be
removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body
boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that
disrupt the integrity of the skin.
DIF: Cognitive Level: Applying REF: 834
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
27. Essential postoperative nursing management of a child after removal of a brain tumor includes which
nursing care?
a.
Turning and positioning every 2 hours
b.
Measuring all fluid intake and output
c.
Changing the dressing when it becomes soiled
d.
Using maximum lighting to ensure accurate observations
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ANS: B
After brain surgery, cerebral edema is a risk. Careful monitoring is essential. All fluids, including intravenous
antibiotics, are included in the intake. Turning and positioning depend on the surgical procedure. When large
tumors are removed, the child is usually not positioned on the operative side. The dressing is not changed. It is
reinforced with gauze after the amount of drainage is marked and estimated. A quiet, dimly lit environment is
optimum to decrease stimulation and relieve discomfort such as headaches.
DIF: Cognitive Level: Applying REF: 835TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
28. An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. What approach
should the nurse implement?
a.
Answer questions with straightforward honesty.
b.
Avoid discussing the seriousness of the condition.
c.
Explain that although the amputation is difficult, it will cure the cancer.
d.
Help the adolescent accept 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 there is time for reflection about the
diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical
surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will
not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be
informed of the need for chemotherapy and its side effects before surgery.
DIF: Cognitive Level: Analyzing REF: 837
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
29. What is an important priority in dealing with the child suspected of having Wilms tumor?
a.
Intervening to minimize bleeding
b.
Monitoring temperature for infection
c.
Ensuring the abdomen is protected from palpation
d.
Teaching parents how to manage the parenteral nutrition
ANS: C
Wilms tumor, or nephroblastoma, is the most common malignant renal and intraabdominal tumor of childhood.
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The abdomen is protected, and palpation is avoided. Careful handling and bathing are essential to prevent
trauma to the tumor site. Before chemotherapy, the child is not myelosuppressed. Bleeding is not usually a risk.
Infection is a concern after surgery and during chemotherapy, not before surgery. Parenteral therapy is not
indicated before surgery.
DIF: Cognitive Level: Understanding REF: 838TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
30. The mother of an infant tells the nurse that sometimes there is a whitish glow in the pupil of his eye. The
nurse should suspect which condition?
a.
Brain tumor
b.
Retinoblastoma
c.
Neuroblastoma
d.
Rhabdomyosarcoma
ANS: B
When the nurse examines the eye, the light will reflect off of the tumor, giving the eye a whitish appearance.
This is called a cats eye reflex. Brain tumors are not usually visible. Neuroblastoma usually arises from the
adrenal medulla and sympathetic nervous system. The most common presentation sites are in the abdomen,
head, neck, or pelvis. Supraorbital ecchymosis may be present with distant metastasis. Rhabdomyosarcoma is a
soft tissue tumor that derives from skeletal muscle undifferentiated cells.
DIF: Cognitive Level: Understanding REF: 840
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
31. The nurse is caring for a 6-year-old child with acute lymphoblastic leukemia (ALL). The parent states, My
child has a low platelet count, and we are being discharged this afternoon. What do I need to do at home? What
statement is most appropriate for the nurse to make?
a.
You should give your child aspirin instead of acetaminophen for fever or pain.
b.
Your child should avoid contact sports or activities that could cause bleeding.
c.
You should feed your child a bland, soft, moist diet for the next week.
d.
Your child should avoid large groups of people for the next week.
ANS: B
A child with a low platelet count needs to avoid activities that could cause bleeding such as playing contact
sports, climbing trees, using playground equipment, or bike riding. The child should be given acetaminophen,
not aspirin, for fever or pain; the child does not need to be on a soft, bland diet or avoid large groups of people
because of the low platelet count.
DIF: Cognitive Level: Applying REF: 823TOP: Nursing Process: Planning
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MSC: Client Needs: Physiological Integrity
32. One pediatric oncologic emergency is acute tumor lysis syndrome. Symptoms that this may be occurring
include what?
a.
Muscle cramps and tetany
b.
Respiratory distress and cyanosis
c.
Thrombocytopenia and sepsis
d.
Upper extremity edema and neck vein distension
ANS: A
Risk factors for development of tumor lysis syndrome include a high white blood cell count at diagnosis, large
tumor burden, sensitivity to chemotherapy, and high proliferative rate. In addition to the described metabolic
abnormalities, children may develop a spectrum of clinical symptoms, including flank pain, lethargy, nausea
and vomiting, muscle cramps, pruritus, tetany, and seizures. Respiratory distress and cyanosis occur with
hyperleukocytosis. Thrombocytopenia and sepsis occur with disseminated intravascular coagulation. Upper
extremity edema and neck vein distention occur with superior vena cava syndrome.
DIF: Cognitive Level: Analyzing REF: 819
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
33. A child has an absolute neutrophil count (ANC) of 500/mm3. The nurse should expect to be administering
which prescribed treatment?
a.
Platelets
b.
Packed red blood cells
c.
Zofran (ondansetron)
d.
G-CSF (Neupogen) daily
ANS: D
G-CSF (filgrastim [Neupogen], pegfilgrastim [Neulasta]) directs granulocyte development and can decrease
the duration of neutropenia following immunosuppressive therapy. G-CSF is discontinued when the ANC
surpasses 10,000/mm3.
DIF: Cognitive Level: Applying REF: 822TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
34. What specific gravity of the urine is desired so that hemorrhagic cystitis is prevented?
a.
1.035
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b.
1.030
c.
1.025
d.
1.005
344
ANS: D
Sterile hemorrhagic cystitis is a side effect of chemical irritation to the bladder from chemotherapy or
radiotherapy. It can be prevented by a liberal oral or parenteral fluid intake (at least one and a half times the
recommended daily fluid requirement). The urine should be dilute so 1.005 is the expected specific gravity.
DIF: Cognitive Level: Analyzing REF: 825
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
35. A child, age 10 years, has a neuroblastoma and is in the hospital for additional chemotherapy treatments.
What laboratory values are most likely this childs?
a.
White blood cell count, 17,000/mm3; hemoglobin, 15 g/dl
b.
White blood cell count, 3,000/mm3; hemoglobin, 11.5 g/dl
c.
Platelets, 450,000/mm3; hemoglobin, 12 g/dl
d.
White blood cell count, 10,000/mm3; platelets, 175,000/mm3
ANS: B
Chemotherapy is the mainstay of therapy for extensive local or disseminated neuroblastoma. The drugs of
choice are vincristine, doxorubicin, cyclophosphamide, cisplatin, etoposide, ifosfamide, and carboplatin. These
cause immunosuppression, so the laboratory values will indicate a low white blood cell count and hemoglobin.
DIF: Cognitive Level: Analyzing REF: 835
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
36. Calculate the absolute neutrophil count (ANC) for the following: WBC count of 5000 mm3; neutrophils
(segs) of 10%; and nonsegmented neutrophils (bands) of 12%.
a.
110/mm3
b.
500/mm3
c.
1100/mm3
d.
5000/mm3
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ANS: C
Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC)
count by percentage of neutrophils.
WBC = 1000/mm3, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7%
Step 1: 10% + 12% = 22%
Step 2: 0.22 5000 = 1100/mm3 ANC
DIF: Cognitive Level: Applying REF: 822TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
37. A child has been diagnosed with a Wilms tumor. What should preoperative nursing care include?
a.
Careful bathing and handling
b.
Monitoring of behavioral status
c.
Maintenance of strict isolation
d.
Administration of packed red blood cells
ANS: A
Careful bathing and handling are important in preventing trauma to the Wilms tumor site.
DIF: Cognitive Level: Applying REF: 839
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
38. What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy?
a.
Mouthwashes with plain saline
b.
Lemon glycerin swabs for cleansing
c.
Mouthwashes with hydrogen peroxide
d.
Swish and swallow with viscous lidocaine
ANS: A
Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method of cleaning the
gums is to wrap a piece of gauze around a finger; soak it in saline or plain water; and swab the gums, palate,
and inner cheek surfaces with the finger. Mouth rinses are best accomplished with plain water or saline
because the child cannot gargle or spit out excess fluid. Avoid agents such as lemon glycerin swabs and
hydrogen peroxide because of the drying effects on the mucosa. Lidocaine should be avoided in young
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children.
DIF: Cognitive Level: Applying REF: 819
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
39. The nurse should expect to care for which age of child if the admitting diagnosis is retinoblastoma?
a.
Infant or toddler
b.
Preschool- or school-age child
c.
School-age or adolescent child
d.
Adolescent
ANS: A
The average age of the child at the time of diagnosis is 2 years, and bilateral and hereditary disease is
diagnosed earlier than unilateral and nonhereditary disease.
DIF: Cognitive Level: Understanding REF: 840
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
40. Postoperative positioning for a child who has had a medulloblastoma brain tumor (infratentorial) removed
should be which?
a.
Trendelenburg
b.
Head of bed elevated above heart level
c.
Flat on operative side with pillows behind the head
d.
Flat, on either side with pillows behind the back
ANS: D
The child with an infratentorial procedure is usually positioned flat and on either side. Pillows should be placed
against the childs back, not head, to maintain the desired position. The Trendelenburg position is
contraindicated in both infratentorial and supratentorial surgeries because it increases intracranial pressure and
the risk of hemorrhage.
DIF: Cognitive Level: Applying REF: 835
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
41. A child is receiving vincristine (Oncovin). The nurse should monitor for which side effect of this
medication?
a.
Diarrhea
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b.
Photosensitivity
c.
Constipation
d.
Ototoxicity
347
ANS: A
Vincristine, and to a lesser extent vinblastine, can cause various neurotoxic effects. One of the more common
neurotoxic effects is severe constipation caused from decreased bowel innervation.
DIF: Cognitive Level: Applying REF: 836
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
42. What chemotherapeutic agent can cause an anaphylactic reaction?
a.
Prednisone (Deltasone)
b.
Vincristine (Oncovin)
c.
L-Asparaginase (Elspar)
d.
Methotrexate (Trexall)
ANS: C
A potentially fatal complication is anaphylaxis, especially from L-asparaginase, bleomycin, cisplatin, and
etoposide (VP-16).
DIF: Cognitive Level: Understanding REF: 817
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
43. A child with cancer being treated with chemotherapy is receiving a platelet transfusion. The nurse
understands that the transfused platelets should survive the body for how many days?
a.
1 to 3 days
b.
4 to 6 days
c.
7 to 9 days
d.
10 to 12 days
ANS: A
Transfused platelets generally survive in the body for 1 to 3 days. The peak effect is reached in about 1 hour
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and decreased by half in 24 hours.
DIF: Cognitive Level: Understanding REF: 823
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
44. Daily toothbrushing and flossing can be encouraged for the child on chemotherapy when the platelet count
is above which?
a.
10,000/mm3
b.
20,000/mm3
c.
30,000/mm3
d.
40,000/mm3
ANS: D
Daily toothbrushing and flossing are encouraged in children with platelet counts above 40,000/mm3.
DIF: Cognitive Level: Analyzing REF: 826TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
45. A parent of a hospitalized child on chemotherapy asks the nurse if a sibling of the hospitalized child should
receive the varicella vaccination. The nurse should give which response?
a.
The sibling can get a varicella vaccination.
b.
The sibling should not get a varicella vaccination.
c.
The sibling should wait until the child is finished with chemotherapy.
d.
The sibling should get varicella-zoster immune globulin if exposed to chickenpox.
ANS: A
Siblings and other family members can receive the live measles, mumps, and rubella vaccine and the varicella
vaccine without risk to the child who is immunosuppressed.
DIF: Cognitive Level: Applying REF: 826
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
46. The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of neuroblastoma. What
finding in the urine is expected with neuroblastomas?
a.
Ketones
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b.
Catecholamines
c.
Red blood cells
d.
Excessive white blood cells
349
ANS: B
Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain, excrete the
catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines is detected in
approximately 95% of children with adrenal or sympathetic tumors.
DIF: Cognitive Level: Analyzing REF: 836TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
47. A child with osteosarcoma is experiencing phantom limb pain after an amputation. What prescribed
medication is effective for short-term phantom pain relief?
a.
Phenytoin (Dilantin)
b.
Gabapentin (Neurontin)
c.
Valproic Acid (Depakote)
d.
Phenobarbital (Phenobarbital)
ANS: B
A recent Cochrane review reported that various medications have been used for phantom limb pain but
complete pain relief has been unsuccessful. Morphine, gabapentin, and ketamine are effective for short-term
pain relief.
DIF: Cognitive Level: Applying REF: 837
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and oncology clinic.
What cardinal signs of cancer in children should the nurse make the new nurse aware of? (Select all that
apply.)
a.
Sudden tendency to bruise easily
b.
Transitory, generalized pain
c.
Frequent headaches
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d.
Excessive, rapid weight gain
e.
Gradual, steady fever
f.
Unexplained loss of energy
350
ANS: A, C, F
The cardinal signs of cancer in children include a sudden tendency to bruise easily; frequent headaches, often
with vomiting; and an unexplained loss of energy. Other cardinal signs include persistent, localized pain;
excessive, rapid weight loss; and a prolonged, unexplained fever.
DIF: Cognitive Level: Applying REF: 816
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
2. A child on chemotherapy has developed rectal ulcers. What interventions should the nurse teach to the child
and parents to relieve the discomfort of rectal ulcers? (Select all that apply.)
a.
Warm sitz baths
b.
Use of stool softeners
c.
Record bowel movements
d.
Use of an opioid for discomfort
e.
Occlusive ointment applied to the area
ANS: A, B, C, E
If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement, and an
occlusive ointment applied to the ulcerated area promote healing; the use of stool softeners is necessary to
prevent further discomfort. Parents should record bowel movements because the child may voluntarily avoid
defecation to prevent discomfort. Opioids would cause increased constipation.
DIF: Cognitive Level: Applying REF: 818
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
3. What are favorable prognostic criteria for acute lymphoblastic leukemia? (Select all that apply.)
a.
Male gender
b.
CALLA positive
c.
Early preB cell
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d.
2 to 10 years of age
e.
Leukocyte count ?7?50,000/mm3
351
ANS: B, C, D
Favorable prognostic criteria for acute lymphoblastic leukemia include CALLA positive, early preB cell, and
age 2 to 10 years. Leukocyte count less, not greater, than 50,000/mm3 and female, not male, gender are
favorable prognostic criteria.
DIF: Cognitive Level: Analyzing REF: 828TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
4. The nurse should teach the family that which residual disabilities can occur for a child being treated for a
brain tumor? (Select all that apply.)
a.
Ataxia
b.
Anorexia
c.
Dysphagia
d.
Sensory deficits
e.
Crania nerve palsies
ANS: A, C, D, E
Even with children who are long-term survivors after treatment for a brain tumor, residual disabilities, such as
short stature, cranial nerve palsies, sensory defects, motor abnormalities (especially ataxia), intellectual
deficits, dysphagia, dysgraphia, and behavioral problems, may occur. Anorexia is not a residual disability.
DIF: Cognitive Level: Applying REF: 835
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse is caring for a child with retinoblastoma that was treated with an enucleation. What interventions
should the nurse plan for care of an eye socket after enucleation? (Select all that apply.)
a.
Clean the prosthesis.
b.
Change the eye pad daily.
c.
Keep the opposite eye covered initially.
d.
Irrigate the socket daily with a prescribed solution.
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352
Apply a prescribed antibiotic ointment after irrigation.
ANS: B, D, E
Care of the socket is minimal and easily accomplished. The wound itself is clean and has little or no drainage.
If an antibiotic ointment is prescribed, it is applied in a thin line on the surface of the tissues of the socket. To
cleanse the site, an irrigating solution may be ordered and is instilled daily or more frequently if necessary
before application of the antibiotic ointment. The dressing consists of an eye pad changed daily. The prosthesis
is not placed until the socket has healed. The opposite eye is not covered.
DIF: Cognitive Level: Applying REF: 843
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
6. What guidelines should the nurse follow when handling chemotherapeutic agents? (Select all that apply.)
a.
Use clean technique.
b.
Prepare medications in a safety cabinet.
c.
Wear gloves designed for handling chemotherapy.
d.
Wear face and eye protection when splashing is possible.
e.
Discard gloves and protective clothing in a special container.
ANS: B, C, D, E
Safe handling of chemotherapeutic agents includes preparing medications in a safety cabinet, wearing gloves
designed for handling chemotherapy, wearing face and eye protection when splashing is possible, and
discarding gloves and protective clothing in a special container. Aseptic, not clean, technique should be used.
DIF: Cognitive Level: Applying REF: 818
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
7. What strategies should the nurse implement to increase nutritional intake for the child receiving
chemotherapy? (Select all that apply.)
a.
Allow the child any food tolerated.
b.
Fortify foods with nutritious supplements.
c.
Allow the child to be involved in food selection.
d.
Encourage the parents to place pressure on the importance of eating.
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353
Encourage the child to eat favorite foods during infusion of chemotherapy medications.
ANS: A, B, C
To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the child any food
tolerated, fortify foods with nutritious supplements, and allow the child to be involved in food selection. The
parents should be encouraged to reduce pressure placed on eating. Some children develop aversions to certain
foods if they are eaten during chemotherapy. It is best to refrain from offering the childs favorite foods while
the child is receiving chemotherapy.
DIF: Cognitive Level: Applying REF: 821
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
COMPLETION
1. A health care provider prescribes ondansetron (Zofran) 0.15 mg/kg intravenously (IV) 30 minutes before
chemotherapy for a child with acute lymphoblastic leukemia. The child weighs 22 kg. The medication label
states: Ondansetron (Zofran) 2 mg/1 ml. The nurse prepares to administer the dose. How many milliliters will
the nurse prepare to administer the dose? Fill in the blank. Round your answer to one decimal place.
________________
ANS:
1.7
Follow the formula for dosage calculation.
22 0.15 = 3.3 mg as the dose
Desired
Volume = ml per dose
Available
3.3 mg
1 ml = 1.65 ml round to 1.7 ml
2 mg
DIF: Cognitive Level: Applying REF: 824
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
2. The health care provider prescribes ceftazidime (Fortaz) 75 mg per intravenous piggyback (IVPB) every 8
hours for a child with cancer admitted with fever and neutropenia. The pharmacy sends the medication to the
unit in a 50-ml bag with directions to run the medication over 30 minutes. What milliliters per hour will the
nurse set the intravenous pump to run the medication over 30 minutes? Fill in the blank and record your answer
in a whole number.
_____________
ANS:
100
Perform the calculation.
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50 ml
________ 60 minutes = 100 ml/hr
30 minutes
DIF: Cognitive Level: Applying REF: 822
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3. The health care provider prescribes vancomycin 200 mg per intravenous piggyback (IVPB) every 6 hours
for a child with cancer admitted to the hospital for fever and neutropenia. The pharmacy sends the medication
to the unit in a 240-ml bag with directions to run the medication over 120 minutes. What milliliters per hour
will the nurse set the intravenous pump to run the medication over 120 minutes? Fill in the blank and record
your answer in a whole number.
_____________
ANS:
120
Perform the calculation.
Convert the minutes to hours = 120/60 = 2 hours
240 ml
________ = 120 ml/hr
2 hours
DIF: Cognitive Level: Applying REF: 822
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
4. A health care provider prescribes Osmitrol (mannitol) 0.25 g/kg intravenously (IV) every 6 hours for a child
after a brain tumor removal. The child weighs 20 kg. The medication label states: Osmitrol (Mannitol) 250
mg/1 ml. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer
the dose? Fill in the blank. Record your answer in a whole number.
________________
ANS:
20
Calculate the dose.
0.25 g 20 = 5 g convert to mg = 5000 mg
Follow the formula for dosage calculation.
Desired
Volume = ml per dose
Available
5000 mg
1 ml = 20 ml
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250 mg
DIF: Cognitive Level: Applying REF: 835
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
5. Calculate the absolute neutrophil count for a child with a WBC = 3000/mm3, neutrophils = 10%, and
nonsegmented neutrophils (bands) = 10%. Record your answer below in a whole number.
_____________
ANS:
600
Perform the calculation
Determine the total percentage of neutrophils (polys, or segs, and bands).
Multiply white blood cell (WBC) count by percentage of neutrophils.
WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10%
Step 1: 10% + 10% = 20%
Step 2: 0.2 3000 = 600/mm3 ANC
DIF: Cognitive Level: Applying REF: 822TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
6. Calculate the absolute neutrophil count for a child with a WBC = 6000/mm3, neutrophils = 18%, and
nonsegmented neutrophils (bands) = 20%. Record your answer below in a whole number.
____________
ANS:
2280
Perform the calculation
Determine the total percentage of neutrophils (polys, or segs, and bands).
Multiply white blood cell (WBC) count by percentage of neutrophils.
WBC = 6000/mm3, neutrophils = 18%, nonsegmented neutrophils (bands) = 20%
Step 1: 18% + 20% = 38%
Step 2: 0.38 6000 = 2280/mm3 ANC
DIF: Cognitive Level: Applying REF: 822TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
7. Calculate the absolute neutrophil count for a child with a WBC = 10,000/mm3, neutrophils = 25%, and
nonsegmented neutrophils (bands) = 22%. Record your answer in a whole number.
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_____________
ANS:
4700
Perform the calculation
Determine the total percentage of neutrophils (polys, or segs, and bands).
Multiply white blood cell (WBC) count by percentage of neutrophils.
WBC = 10,000/mm3, neutrophils = 25%, and nonsegmented neutrophils (bands) = 22%
Step 1: 25% + 22% = 47%
Step 2: 0.47 10,000 = 4700/mm3 ANC
DIF: Cognitive Level: Applying REF: 822TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
8. Calculate the absolute neutrophil count for a child with a WBC = 15,000/mm3, neutrophils = 29%, and
nonsegmented neutrophils (bands) = 29%. Record your answer in a whole number.
_____________
ANS:
8700
Perform the calculation
Determine the total percentage of neutrophils (polys, or segs, and bands).
Multiply white blood cell (WBC) count by percentage of neutrophils.
WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10%
Step 1: 29% + 29% = 58%
Step 2: 0.58 15,000 = 8700/mm3 ANC
DIF: Cognitive Level: Applying REF: 822TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
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Chapter 26: The Child with Genitourinary Dysfunction
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: 850
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is admitting a school-age child in acute renal failure with reduced glomerular filtration rate.
Which urine test is the most useful clinical indication of glomerular filtration rate?
a. pH
b. Osmolality
c. Creatinine
d. Protein level
ANS: C
The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a substance that is
freely filtered by the glomerulus and secreted by the renal tubule cells. The pH and osmolality are not estimates
of glomerular filtration. Although protein in the urine demonstrates abnormal glomerular permeability, it is not
a measure of filtration rate.
PTS: 1 DIF: Cognitive Level: Understand REF: 846
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: 848
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?
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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: 850
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: 852
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this
newborn?
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: 854
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: 854
TOP: Integrated Process: Teaching/Learning
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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: 856
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. Which is instituted for the therapeutic management of minimal change nephrotic syndrome?
a. Corticosteroids
b. Antihypertensive agents
c. Long-term diuretics
d. Increased fluids to promote diuresis
ANS: A
Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response is usually seen
within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are usually not necessary. A diet
that has fluid and salt restrictions may be indicated.
PTS: 1 DIF: Cognitive Level: Apply REF: 856
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: 856
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.
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The child will most likely have neurologic signs and symptoms.
PTS: 1 DIF: Cognitive Level: Understand REF: 856
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.
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: 856
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. Which is included in the diet of a child with minimal change nephrotic syndrome?
a. High protein
b. Salt restriction
c. Low fat
d. High carbohydrate
ANS: B
Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the
acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide
nutritionally complete meals.
PTS: 1 DIF: Cognitive Level: Understand REF: 856
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: 857
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.
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 857
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: 858
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: 858
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: 858
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
19. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
a. Risk for Injury related to malignant process and treatment
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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: 857
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: 859
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: 861
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
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: 861
TOP: Integrated Process: Nursing Process: Assessment
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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: 862
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: 863
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 863
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.
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PTS: 1 DIF: Cognitive Level: Understand REF: 864
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: 864
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: 864
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
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 calciumphosphorus 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: 864
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
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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: 865
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: 865
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?
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: 867
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: 849
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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: 867
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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 thrice-weekly 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: 858
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: 862
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
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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.
PTS: 1 DIF: Cognitive Level: Understand REF: 851
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: 858
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 frothy-appearing 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: 856
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
The IV urography is a test done to provide information about the integrity of the kidneys, ureters, and bladder.
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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: 847
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.
PTS: 1 DIF: Cognitive Level: Analyze REF: 849
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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Chapter 27: The Child with Cerebral Dysfunction
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 874
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse has received report on four children. Which child should the nurse assess first?
a. A school-age child in a coma with stable vital signs
b. A preschool child with a head injury and decreasing level of consciousness
c. An adolescent admitted after a motor vehicle accident is oriented to person and place
d. A toddler in a persistent vegetative state with a low-grade fever
ANS: B
The nurse should assess the child with a head injury and decreasing level of consciousness first (LOC).
Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The
next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The
school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to
his surroundings would be of least worry to the nurse.
PTS: 1 DIF: Cognitive Level: Apply REF: 873
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head injury. The child opens
eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse
should record?
a. 8
b. 11
c. 13
d. 15
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal response, and motor
response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of
these numeric values provides an objective measure of the 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: 874
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.
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b. neurosurgical emergency.
c. severe brainstem damage.
d. indication of brain death.
ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should
immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has
experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils for more than 5 minutes are indicative
of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the
brain. One fixed and dilated pupil is not suggestive of brain death.
PTS: 1 DIF: Cognitive Level: Analyze REF: 887
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: 875
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: 876
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function.
The nurse should include which statement in preparing the child?
a. Pain medication will be given.
b. The scan will not hurt.
c. You will be able to move once the equipment is in place.
d. Unfortunately, no one can remain in the room with you during the test.
ANS: B
For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the
procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able
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to remain with the child during the procedure.
PTS: 1 DIF: Cognitive Level: Apply REF: 878
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which neurologic diagnostic test gives a visualized horizontal and vertical cross-section of the brain at any
axis?
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: 878
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: 880
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: 881
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.
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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: 882
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: 884
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 885
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: 885
TOP: Integrated Process: Nursing Process: Assessment
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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: 888
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: 887
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: 875
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.
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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: 887
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 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: 878
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: 874
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
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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: 889
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.
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: 889
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: 890
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: 892
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?
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a. Removal of tumor will stop the various symptoms.
b. Usually the postoperative dressing covers the entire scalp.
c. He is not old enough to be concerned about his head being shaved.
d. He is not old enough to understand the significance of the brain.
ANS: B
The child should be told what he will look and feel like after surgery. This includes the size of the dressing.
The nurse can demonstrate on a doll the expected size and shape of the dressing. Some of the symptoms may
be alleviated by the removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia
may be aggravated. Children should be prepared for the loss of their hair, and it should be removed in a
sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and
little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the
integrity of the skin.
PTS: 1 DIF: Cognitive Level: Apply REF: 893
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: 894
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: 895
TOP: Integrated Process: Teaching/Learning
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.
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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: 899
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: 901
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: 901
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.
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-ofmotion 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: 901
TOP: Integrated Process: Nursing Process: Implementation
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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: 900
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: 901
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
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: 902
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
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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: 903
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: 903
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 prevent aspiration, if possible, the child should be placed
on the side, facilitating drainage.
PTS: 1 DIF: Cognitive Level: Apply REF: 907
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: 910
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
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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: 905
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 910
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: 913
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: 893
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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: 893
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: 892
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: 874
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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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
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: 914
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 3-year-old child with
bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.)
a. Elevated white blood cell (WBC) count
b. Decreased glucose
c. Normal protein
d. Elevated red blood cell (RBC) count
ANS: A, B
The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased glucose, and
increased protein content. There should not be RBCs evident in the CSF fluid.
PTS: 1 DIF: Cognitive Level: Analyze REF: 899
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: 891
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: 874
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 highest-priority intervention sequencing to the lowestpriority 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.
PTS: 1 DIF: Cognitive Level: Apply REF: 907
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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Chapter 28: The Child with Endocrine Dysfunction
1. Which of the following statements best describes hypopituitarism?
a. Growth is normal during the first 3 years of life.
b. Weight is usually more retarded than height.
c. Skeletal proportions are normal for age.
d. Most of these children have subnormal intelligence.
ANS: C
In children with hypopituitarism, the skeletal proportions are normal.
DIF: Cognitive Level: Comprehension REF: 912
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing considerations
should be based on knowledge of which of the following?
a. Treatment is most successful if it is started during adolescence.
b. Treatment is considered successful if children attain full stature by adulthood.
c. Replacement therapy requires daily subcutaneous injections.
d. Replacement therapy will be required throughout child’s lifetime.
ANS: C
Additional support is required for children who require hormone replacement therapy, such as preparation for
daily subcutaneous injections and education for self- management during the school-age years.
DIF: Cognitive Level: Analysis REF: 916
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
3. A child with GH deficiency is receiving GH therapy. When is the best time for the GH to be administered?
a. At bedtime
b. After meals
c. Before meals
d. On arising in the morning
ANS: A
Injections are best given at bedtime to more closely approximate the physiologic release of GH.
DIF: Cognitive Level: Application REF: 917
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
4. Which of the following is a condition that can result if hypersecretion of GH occurs after epiphyseal
closure?
a. Dwarfism
b. Acromegaly
c. Gigantism
d. Cretinism
ANS: B
Excess GH after closure of the epiphyseal plates results in acromegaly.
DIF: Cognitive Level: Comprehension REF: 917
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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5. At what age is sexual development in boys and girls considered to be precocious?
a. Boys, 11 years; girls, 9 years
b. Boys, 12 years; girls, 10 years
c. Boys, 9 years; girls, 8 years
d. Boys, 10 years; girls, 9-1/2 years
ANS: C
Manifestations of sexual development before age 9 in boys and age 8 in girls is considered precocious and
should be investigated.
DIF: Cognitive Level: Comprehension REF: 917
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. A child will start treatment for precocious puberty. This involves injections of synthetic:
a. thyrotropin.
b. gonadotropins.
c. somatotropic hormone.
d. luteinizing hormone–releasing hormone.
ANS: D
Precocious puberty of central origin is treated with monthly subcutaneous injections of luteinizing hormone–
releasing hormone.
DIF: Cognitive Level: Comprehension REF: 918
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PhysiologicIntegrity:PharmacologicandParenteral Therapy
7. Diabetes insipidus is a disorder of which of the following?
a. Anterior pituitary
b. Posterior pituitary
c. Adrenal cortex
d. Adrenal medulla
ANS: B
The principal disorder of posterior pituitary hypofunction is diabetes insipidus.
DIF: Cognitive Level: Comprehension REF: 918
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. The nurse is caring for a child with suspected diabetes insipidus. Which of the following clinical
manifestations would the nurse expect to observe?
a. Oliguria
b. Glycosuria
c. Nausea and vomiting
d. Polyuria and polydipsia
ANS: D
Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of diabetes. These
symptoms may be so severe that the child does little other than drink and urinate.
DIF: Cognitive Level: Application REF: 918
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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9. A nasal spray of desmopressin acetate (DDAVP) is used to treat:
a. hypopituitarism.
b. diabetes insipidus.
c. acute adrenocortical insufficiency.
d. syndrome of inappropriate ADH.
ANS: B
The drug of choice for the treatment of diabetes insipidus is DDAVP, which is a synthetic analog of
vasopressin.
DIF: Cognitive Level: Comprehension REF: 919
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
10. Which of the following is a common clinical manifestation of juvenile hypothyroidism?
a. Insomnia
b. Diarrhea
c. Dry skin
d. Accelerated growth
ANS: C
Dry skin, mental decline, and myxedematous skin changes are associated with juvenile hypothyroidism.
DIF: Cognitive Level: Comprehension REF: 920
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. A goiter is an enlargement or hypertrophy of which gland?
a. Thyroid
b. Adrenal
c. Anterior pituitary
d. Posterior pituitary
ANS: A
A goiter is an enlargement or hypertrophy of the thyroid gland.
DIF: Cognitive Level: Comprehension REF: 921
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Exophthalmos (protruding eyeballs) may occur in children with which of the following conditions?
a. Hypothyroidism
b. Hyperthyroidism
c. Hypoparathyroidism
d. Hyperparathyroidism
ANS: B
Exophthalmos is a clinical manifestation of hyperthyroidism.
DIF: Cognitive Level: Comprehension REF: 922
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is teaching the parents of a child who is receiving propylthiouracil for the treatment of
hyperthyroidism (Graves disease). Which of the following statements made by the parent indicates a correct
understanding of the teaching?
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a. “I would expect my child to gain weight while taking this medication.”
b. “I would expect my child to experience episodes of ear pain while taking this medication.”
c. “If my child develops a sore throat and fever, I should contact the physician immediately.”
d. “If my child develops the stomach flu, my child will need to be hospitalized.”
ANS: C
Children being treated with propylthiouracil must be carefully monitored for the side effects of the drug.
Parents must be alerted that sore throat and fever accompany the grave complication of leukopenia. These
symptoms should be immediately reported.
DIF: Cognitive Level: Application REF: 923
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
14. Which of the following clinical manifestations may occur in the child who is receiving too much
propylthiouracil for the treatment of hyperthyroidism (Graves disease)?
a. Seizures
b. Enlargement of all lymph glands
c. Pancreatitis or cholecystitis
d. Lethargy and somnolence
ANS: D
Parents should be aware of the signs of hypothyroidism that can occur from overdosage of the drug. The most
common manifestations are lethargy and somnolence.
DIF: Cognitive Level: Comprehension REF: 923
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
15. A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch
for which of the following signs of vitamin D toxicity?
a. Headache and seizures
b. Physical restlessness and voracious appetite without weight gain
c. Weakness and lassitude
d. Anorexia and insomnia
ANS: C
Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for signs, including
weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal impairment is manifested
through polyuria, polydipsia, and nocturia.
DIF: Cognitive Level: Application REF: 924
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
16. Glucocorticoids, mineralocorticoids, and sex steroids are secreted by the:
a. thyroid gland.
b. parathyroid glands.
c. adrenal cortex.
d. anterior pituitary.
ANS: C
These hormones are secreted by the adrenal cortex.
DIF: Cognitive Level: Comprehension REF: 925
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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17. Chronic adrenocortical insufficiency is also referred to as:
a. Graves disease.
b. Addison disease.
c. Cushing syndrome.
d. Hashimoto disease.
ANS: B
Addison disease is chronic adrenocortical insufficiency.
DIF: Cognitive Level: Comprehension REF: 926
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital hyperplasia.
Therapeutic management includes administration of:
a. vitamin D.
b. cortisone.
c. stool softeners.
d. calcium carbonate.
ANS: B
Cortisone is administered to suppress the abnormally high secretions of adrenocorticotropic hormone (ACTH).
This in turn inhibits the secretion of adrenocorticosteroid, which stems the progressive virilization.
DIF: Cognitive Level: Analysis REF: 929
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
19. The parents of a neonate with adrenogenital hyperplasia tell the nurse that they will be afraid to have any
more children. The nurse should explain that:
a. it is not hereditary.
b. genetic counseling is indicated.
c. it can be prevented during pregnancy.
d. all future children will have the disorder.
ANS: B
Some forms of adrenogenital hyperplasia are hereditary and should be referred for genetic counseling.
Affected offspring should also be referred for genetic counseling.
DIF: Cognitive Level: Analysis REF: 930
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. Which of the following is characteristic of the immune-mediated type 1 diabetes mellitus?
a. Ketoacidosis is infrequent.
b. Onset is gradual.
c. Age at onset is usually younger than 20 years.
d. Oral agents are often effective for treatment.
ANS: C
The immune-mediated type 1 diabetes mellitus typically has its onset in children or young adults.
DIF: Cognitive Level: Analysis REF: 931
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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21. Which of the following is considered a cardinal sign of diabetes mellitus?
a. Nausea
b. Seizures
c. Impaired vision
d. Frequent urination
ANS: D
Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia.
DIF: Cognitive Level: Comprehension REF: 932
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: AreaofClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
22. Hyperglycemia associated with diabetic ketoacidosis is defined as a blood glucose measurement equal to or
greater than:
a. 185 mg/dl.
b. 220 mg/dl.
c. 280 mg/dl.
d. 330 mg/dl.
ANS: D
Diabetic ketoacidosis is a state of relative insulin insufficiency and may include the presence of
hyperglycemia, a blood glucose level greater than or equal to 330 mg/dl.
DIF: Cognitive Level: Comprehension REF: 933
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. Type 1 diabetes mellitus is suspected in an adolescent. Which of the following clinical manifestations may
be present?
a. Moist skin
b. Weight gain
c. Fluid overload
d. Poor wound healing
ANS: D
Poor wound healing may be present in an individual with type 1 diabetes mellitus.
DIF: Cognitive Level: Comprehension REF: 932
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. A parent asks the nurse why self-monitoring of blood glucose is being recommended for her child with
diabetes. The nurse should base the explanation on which of the following?
a. It is a less expensive method of testing.
b. It is not as accurate as laboratory testing.
c. Children are better able to manage the diabetes.
d. The parents are better able to manage the disease.
ANS: C
Blood glucose self-management has improved diabetes management and can be used successfully by children
from the time of diagnosis. Insulin dosages can be adjusted based on blood glucose results.
DIF: Cognitive Level: Analysis REF: 935
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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25. The parent of a child with diabetes mellitus asks the nurse when urine testing will be necessary. The nurse
should explain that urine testing for:
a. glucose is needed before administration of insulin.
b. glucose is needed four times a day.
c. glycosylated hemoglobin is required.
d. ketonuria should be done when it is suspected.
ANS: D
Urine testing is still performed to detect evidence of ketonuria.
DIF: Cognitive Level: Comprehension REF: 931
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. The nurse
should explain that:
a. exercise will increase blood glucose.
b. exercise should be restricted.
c. extra snacks are needed before exercise.
d. extra insulin is required during exercise.
ANS: C
Exercise lowers blood glucose levels, which can be compensated for by extra snacks.
DIF: Cognitive Level: Application REF: 931
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-releasing sugar
should be followed by which of the following?
a. Fat
b. Fruit juice
c. Several glasses of water
d. Complex carbohydrate and protein
ANS: D
Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a complex
carbohydrate and protein.
DIF: Cognitive Level: Application REF: 935
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. Manifestations of hypoglycemia include which of the following?
a. Lethargy
b. Thirst
c. Nausea and vomiting
d. Shaky feeling and dizziness
ANS: D
Some of the clinical manifestations of hypoglycemia include shaky feelings; dizziness; difficulty
concentrating, speaking, focusing, or coordinating; sweating; and pallor.
DIF: Cognitive Level: Comprehension REF: 936
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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29. The nurse is caring for an 11-year-old boy who has recently been diagnosed with diabetes. Which of the
following should be included in the teaching plan for daily injections?
a. The parents do not need to learn the procedure.
b. He is old enough to give most of his own injections.
c. Self-injections will be possible when he is closer to adolescence.
d. He can learn about self-injections when he is able to reach all injection sites.
ANS: B
School-age children are able to give their own injections.
DIF: Cognitive Level: Application REF: 930
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
30. The nurse is discussing with a child and family the various sites used for insulin injections. Which of the
following sites usually has the fastest rate of absorption?
a. Arm
b. Leg
c. Buttock
d. Abdomen
ANS: D
The abdomen has the fastest rate of absorption but the shortest duration.
DIF: Cognitive Level: Application REF: 942
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
31. To help the adolescent deal with diabetes, the nurse must consider which of the following characteristics of
adolescence?
a. Desire to be unique
b. Preoccupation with the future
c. Need to be perfect and similar to peers
d. Need to make peers aware of the seriousness of hypoglycemic reactions
ANS: C
Adolescence is a time when the individual wants to be perfect and similar to peers. Having diabetes makes
adolescents different from their peers.
DIF: Cognitive Level: Analysis REF: 930
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. Nursing care of a child diagnosed with syndrome of inappropriate ADH should include which of the
following? (Select all that apply.)
a. Weigh daily.
b. Encourage fluids.
c. Turn frequently.
d. Maintain nothing by mouth (NPO).
e. Restrict fluids.
ANS: A, E
Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid volume and decreases
serum osmolarity with a progressive reduction in sodium concentration. The immediate management of the
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child is to restrict fluids. The child should also be weighed at the same time each day.
DIF: Cognitive Level: Analysis REF: 919
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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Chapter 29: The Child with Musculoskeletal or Articular Dysfunction
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: 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is caring for a preschool child immobilized by a spica cast. Which effect on metabolism should
the nurse monitor on this child related to the immobilized status?
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.
PTS: 1 DIF: Cognitive Level: Understand REF: 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse should monitor for which effect on the cardiovascular system when a child is immobilized?
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: 944
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Po