Chapter 01: Children, Their Families, and the Nurse
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse would include which associated risk when planning a teaching session about
childhood obesity?
Type I diabetes
Respiratory disease
Celiac disease
Type II diabetes
a.
b.
c.
d.
ANS: D
Childhood obesity has been associated with the rise of type II diabetes in children. Type I
diabetes is not associated with obesity and has a genetic component. Respiratory disease is not
associated with obesity, and celiac disease is the inability to metabolize gluten in foods and is
not associated with obesity.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which second-leading cause of death topic would the nurse emphasize to a group of boys
ranging in age from 15 to 19 years?
Suicide
Cancer
Homicide
Occupational injuries
a.
b.
c.
d.
ANS: C
Firearm homicide is the second overall cause of death in this age group and the leading cause
of death in African-American males. Suicide is the third-leading cause of death in this
population. Cancer, although a major health problem, is the fourth-leading cause of death in
this age group. Occupational injuries do not contribute to a significant death rate for this age
group.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is the major cause of death for children older than 1 year?
a. Cancer
b. Heart disease
c. Unintentional injuries
d. Congenital anomalies
ANS: C
Unintentional injuries (accidents) are the leading cause of death after age 1 year through
adolescence. Congenital anomalies are the leading cause of death in those younger than 1
year. Cancer ranks either second or fourth, depending on the age group, and heart disease
ranks fifth in the majority of the age groups.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which factor most impacts the type of injury a child is susceptible to, according to the child’s
age?
Physical health of the child
Developmental level of the child
Educational level of the child
Number of responsible adults in the home
a.
b.
c.
d.
ANS: B
The child’s developmental stage determines the type of injury that is likely to occur. The
child’s physical health may facilitate the child’s recovery from an injury but does not impact
the type of injury. Educational level is related to developmental level, but it is not as important
as the child’s developmental level in determining the type of injury. The number of
responsible adults in the home may affect the number of unintentional injuries, but the type of
injury is related to the child’s developmental stage.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. A nurse on a pediatric unit is practicing family-centered care. Which is most descriptive of the
care the nurse is delivering?
Taking over total care of the child to reduce stress on the family
Encouraging family dependence on health care systems
Recognizing that the family is the constant in a child’s life
Excluding families from the decision-making process
a.
b.
c.
d.
ANS: C
The three key components of family-centered care are respect, collaboration, and support.
Family-centered care recognizes the family as the constant in the child’s life. Taking over total
care does not include the family in the process and may increase stress instead of reducing
stress. The family should be enabled and empowered to work with the health care system. The
family is expected to be part of the decision-making process.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which intervention would the nurse include when providing atraumatic care?
a. Prepare the child for separation from parents during hospitalization by reviewing a
video.
b. Prepare the child before any unfamiliar treatment or procedure.
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
7. Which is suggestive that a nurse has a nontherapeutic relationship with a patient and family?
a. Staff is concerned about the nurse’s closeness 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
A clue to a nontherapeutic staff-patient relationship is concern by other staff members.
Allowing the nurse to care for the same patient over time would be therapeutic for the patient
and family. Nurses who are able to somewhat withdraw emotionally can protect themselves
while providing therapeutic care. Nurses using teaching skills to instruct patient and family
will assist in transitioning the child and family to self-care.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
8. Which is descriptive of clinical reasoning?
a. A simple developmental process
b. A cognitive process used to analyze data
c. Based on deliberate and irrational thought
d. Assists individuals in guessing which is most appropriate
ANS: B
Clinical reasoning is a complex, developmental process based on rational and deliberate
thought. Clinical reasoning is not a developmental process. Clinical reasoning is based on
rational and deliberate thought. Clinical reasoning is not a guessing process.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
9. A nurse makes the decision to apply a topical anesthetic to a child’s skin before drawing
blood. Which ethical principle is the nurse demonstrating?
a. Autonomy
b. Beneficence
c. Justice
d. Truthfulness
ANS: B
Beneficence is the obligation to promote the patient’s well-being. Applying a topical
anesthetic before drawing blood promotes reducing the discomfort of the venipuncture.
Autonomy is the patient’s right to be self-governing. Justice is the concept of fairness.
Truthfulness is the concept of honesty.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity
10. Which action by the nurse demonstrates use of evidence-based practice (EBP)?
a. Gathering equipment for a procedure
b. Documenting changes in a patient’s status
c. Questioning the practice of daily central line dressing changes
d. Clarifying a physician’s 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 EBP, which implies
questioning why something is effective and whether a better approach exists. Gathering
equipment for a procedure and documenting changes in a patient’s status are practices that
follow established guidelines. Clarifying a physician’s prescription for morphine constitutes
safe nursing care.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
11. A nurse is admitting a toddler to the hospital and the parents state they will need to leave for a
brief period. Which type of nursing diagnosis would the nurse formulate for this child?
Risk for anxiety
Anxiety
Readiness for enhanced coping
Ineffective coping
a.
b.
c.
d.
ANS: A
A potential problem is categorized as a risk. The toddler has a risk to become anxious when
the parents leave. Nursing interventions will be geared toward reducing the risk. The child is
not showing current anxiety or ineffective coping. The child is not at a point for readiness for
enhanced coping, especially because the parents will be leaving.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
12. Which depicts accurate documentation for a dressing change on a child who has an
appendectomy incision?
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 patient’s response and the outcomes of the care provided. In this example, these
include drainage on the old dressing, the application of the new dressing, and the child’s
response. The other statements partially fulfill the requirements of documenting assessments
and reassessments, patient’s response, and outcome, but do not include all three.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
13. A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic
is the priority for this class?
a. Correct 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. A nurse is collecting subjective and objective information about target populations to diagnose
problems based on community needs. This describes which step in the community nursing
process?
a. Planning
b. Diagnosis
c. Assessment
d. Establishing objectives
ANS: C
Assessment is a continuous process that operates at all phases of problem solving and is the
foundation for decision making. Assessment involves multiple nursing skills and consists of
the purposeful collection, classification, and analysis of data from a variety of sources.
Diagnosing is the next step of the nursing process when the problem is identified. The nurse
should establish objectives for the activity before starting the nursing process.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
15. A nurse has established several health programs, such as bicycle safety, to improve the health
status of a target population. This describes which step in the community nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS: D
The nurse working with the community to put into practice a program to reach community
goals is the implementation phase of the community nursing process. Planning involves
designing the program to meet community-centered goals. The evaluation stage would
determine the effectiveness of the program. During the assessment phase, the nurse would
identify the resources necessary and the barriers that would interfere with implementation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
16. When communicating with other professionals, which is important for the nurse to do?
a. Ask others what they want to know.
b. Share everything known about the family.
c. Restrict communication to clinically relevant information.
d. Recognize that confidentiality is not possible.
ANS: C
The nurse will need to share, through both oral and written communication, clinically relevant
information with other involved health professionals. Asking others what they want to know
and sharing everything known about the family is inappropriate. Patients have a right to
confidentiality. The nurse is not permitted to share information about clients, except clinically
relevant information that pertains to the child’s care. Confidentiality permits the disclosure of
information to other health professionals on a need-to-know basis.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
17. A nurse is formulating a clinical question for evidence-based practice. Place in sequential
order the steps the nurse should use to clarify the scope of the problem and clinical topic of
interest:
1. Intervention
2. Outcome
3. Population
4. Time
5. Comparison
a. 4, 5, 1, 2, 1
b. 5, 2, 3, 4, 1
c. 3, 1, 5, 2, 4
d. 2, 3, 1, 5, 4
ANS: C
When formulating a clinical question for evidence-based practice, the nurse would follow a
concise, organized way that allows for clear answers. Good clinical questions should be asked
in the PICOT (population, intervention, comparison, outcome, time) format to assist with
clarity and literature searching. PICOT questions assist with clarifying the scope of the
problem and clinical topic of interest.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The following account for nearly half of all deaths in infants younger than 1 year? (Select all
that apply.)
Congenital anomalies
Sudden infant death syndrome
Respiratory distress syndrome
Bacterial sepsis of the newborn
Disorders relating to short gestation
a.
b.
c.
d.
e.
ANS: A, B, E
Congenital anomalies, disorders relating to short gestation and unspecified LBW, newborn
affected by maternal complications of pregnancy, and sudden infant death syndrome—
accounted for about half (49.8%) of all deaths of infants younger than 1 year old (Centers for
Disease Control and Prevention, 2017a).
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which behaviors by the nurse indicate a therapeutic relationship with children and families?
(Select all that apply.)
Spending off-duty time with children and families
Asking questions if families are not participating in the care
Clarifying information for families
Buying toys for a hospitalized child
Learning about the family’s religious preferences
a.
b.
c.
d.
e.
ANS: B, C, E
Asking questions if families are not participating in the care, clarifying information for
families, and learning about the family’s religious preferences are positive actions and foster
therapeutic relationships with children and families. Spending off-duty time with children and
families and buying toys for a hospitalized child are negative actions and indicate
overinvolvement with children and families, which is nontherapeutic.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
3. Which behaviors by the nurse indicate non-therapeutic relationship with children and
families? (Select all that apply.)
a. Visits family on days off.
b. Provides a calming influence
c. Purchases clothes and toys for the child.
d. Communication is open and two-way.
e. Strives to empower families.
ANS: A, C
A home care nurse can establish therapeutic nurse-family boundaries by negotiating house
rules and ensuring that communication is open and two-way. Visiting the family of off-duty
days and buying expensive gifts for the child would be boundary crossing and nontherapeutic.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
Chapter 02: Social, Cultural, Religious, and Family Influences on Child Health
Promotion
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which family theory best describes a series of tasks for the family throughout its life span?
a. Bowen’s family systems theory
b. Family stress theory
c. General systems theory
d. Duvall’s developmental theory
ANS: D
Duvall’s developmental theory describes eight developmental tasks of the family throughout
its life span. Interactional theory and structural-functional theory are not family theories.
Developmental systems theory is an outgrowth of Duvall’s theory. The family is described as
a small group, a semiclosed system of personalities that interact with the larger cultural
system. Changes do not occur in one part of the family without changes in others.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which is the term for a family in which the paternal grandmother, the parents, and two minor
children live together?
a. Blended
b. Nuclear
c. Binuclear
d. Extended
ANS: D
An extended family contains at least one parent, one or more children, and one or more
members (related or unrelated) other than a parent or sibling. A blended family contains at
least one stepparent, step-sibling, or half-sibling. The nuclear family consists of two parents
and their children. No other relatives or nonrelatives are present in the household. In binuclear
families, parents continue the parenting role while terminating the spousal unit. For example,
when joint custody is assigned by the court, each parent has equal rights and responsibilities
for the minor child or children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. 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 stepparent, step-sibling, or half-sibling. The nuclear
family consists of two parents and their children. No other relatives or nonrelatives are present
in the household. In binuclear families, parents continue the parenting role while terminating
the spousal unit. For example, when joint custody is assigned by the court, each parent has
equal rights and responsibilities for the minor child or children. An extended family contains
at least one parent, one or more children, and one or more members (related or unrelated)
other than a parent or sibling.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. When assessing a family, the nurse determines that the parents exert little or no control over
their children. This is reflective of which parenting style?
Permissive
Dictatorial
Democratic
Authoritarian
a.
b.
c.
d.
ANS: A
Permissive parents avoid imposing their own standards of conduct and allow their children to
regulate their own activity as much as possible. The parents exert little or no control over their
children’s actions. Dictatorial or authoritarian parents attempt to control their children’s
behavior and attitudes through unquestioned mandates. They establish rules and regulations or
standards of conduct that they expect to be followed rigidly and unquestioningly. Democratic
parents combine permissive and dictatorial styles. They direct their children’s behavior and
attitudes by emphasizing the reasons for rules and negatively reinforcing deviations. They
respect the child’s individual nature.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
5. When discussing discipline with the mother of a 4-year-old child, the nurse would include
which instruction?
Children as young as 4 years old rarely need to be punished.
Parental control should be consistent.
Withdrawal of love and approval is effective at this age.
One should expect rules to be followed rigidly and unquestioningly.
a.
b.
c.
d.
ANS: B
For effective discipline, parents must be consistent and must follow through with agreed-on
actions. Realistic goals should be set for this age group. Parents should structure the
environment to prevent unnecessary difficulties. Requests for behavior change should be
phrased in a positive manner to provide direction for the child. Withdrawal of love and
approval is never appropriate or effective. Discipline strategies should be appropriate to the
child’s age, temperament, and severity of the misbehavior. Following rules rigidly and
unquestioningly is beyond the developmental capabilities of a 4-year-old.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which is most characteristic of the physical punishment of children, such as spanking?
a.
b.
c.
d.
Psychological impact is usually minimal.
Children rarely become accustomed to spanking.
Children’s development of reasoning increases.
Misbehavior is likely to occur when parents are not present.
ANS: D
Through the use of physical punishment, children learn what they should not do. When
parents are not around, it is more likely that children will misbehave because they have not
learned to behave well for their own sake, but rather out of fear of punishment. Spanking can
cause severe physical and psychological injury and interfere with effective parent-child
interaction. Children do become accustomed to spanking, requiring more severe corporal
punishment each time. The use of corporal punishment may interfere with the child’s
development of moral reasoning.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
7. The parents of a 3-year-old adopted daughter have just asked the nurse how they should tell
the child that she is adopted. Which guidelines concerning adoption would the nurse use in
planning a response?
a. Telling the child is an important aspect of their parental responsibilities.
b. The best time to tell the child is between ages 7 and 10 years.
c. It is not necessary to tell the child who was adopted so young.
d. It is best to wait until the child asks about it.
ANS: A
It is important for the parents not to withhold information about the adoption from the child. It
is an essential component of the child’s identity. There is no recommended best time to tell
children. It is believed that children should be told young enough so they do not remember a
time when they did not know. It should be done before the children enter school to keep third
parties from telling the children before the parents have had the opportunity.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. A parent of a school-age child is going through a divorce, and the parent tells the school nurse
the child has not been doing well in school and sometimes has trouble sleeping. The nurse
would recognize this as which implication?
a. Indication of maladjustment
b. Common reaction to divorce
c. Lack of adequate parenting
d. Unusual response that indicates need for referral
ANS: B
Parental divorce affects school-age children in many ways. In addition to difficulties in
school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of
appetite, and sleep disorders. This is not an indication of maladjustment, suggestive of lack of
adequate parenting, or an unusual response that indicates need for referral in school-age
children after parental divorce.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
9. During a well-baby visit, the mother of 6-month-old comments, “I want to go back to work,
but I don’t want my baby to suffer because I’ll have less time with him.” A therapeutic
response by the nurse includes which statement?
a. “I’m sure he’ll be fine if you get a good babysitter.”
b. “You will need to stay home until Eric starts school.”
c. “You should go back to work so Eric will get used to being with others.”
d. “Let’s talk about the child care options that will be best for your baby.”
ANS: D
Let’s talk about the child care options that will be best for the baby is an open-ended statement
that will assist the mother in exploring her concerns about what is best for both her and the
child. I’m sure he’ll be fine if you get a good babysitter, You will need to stay home until the
baby starts school, and You should go back to work so the baby will get used to being with
others are directive statements. They do not address the effect on the baby of her working
outside the home.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
10. 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?
Race
Culture
Ethnicity
Social group
a.
b.
c.
d.
ANS: B
Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides
the outlook and decisions of a group of people. A culture is composed of individuals who
share a set of values, beliefs, and practices that serve as a frame of reference for individual
perceptions and judgments. Race is defined as a division of humankind possessing traits that
are transmissible by descent and are sufficient to characterize it as a distinct human type.
Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic
heritage. A social group consists of systems of roles carried out in groups. Examples of
primary social groups include the family and peer groups.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. Dunst, Trivette, and Deal identified the qualities of strong families that help them function
effectively. Which qualities are included? (Select all that apply.)
a. Ability to stay connected without spending time together
b. Clear set of family values, rules, and beliefs
c. Adoption of one coping strategy that always promotes positive functioning in
dealing with life events
d. Sense of commitment toward growth of individual family members as opposed to
that of the family unit
e. Ability to engage in problem-solving activities
f. Sense of balance between the use of internal and external family resources
ANS: B, E, F
A clear set of family rules, values, and beliefs that establishes expectations about acceptable
and desired behavior is one of the qualities of strong families that help them function
effectively. Strong families also are able to engage in problem-solving activities and to find a
balance between internal and external forces. Strong families have a sense of congruence
among family members regarding the value and importance of assigning time and energy to
meet needs. Strong families also use varied coping strategies. The sense of commitment is
toward the growth and well-being of individual family members, as well as the family unit.
DIF: Cognitive Level: Understand
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 strategies would the nurse include? (Select all that apply.)
Time-out as a discipline measure cannot be used when in a public place.
A rule for the length of time-out is 1 minute per year.
When the child misbehaves, one warning should be given.
The area for time-out is safe, convenient, and where the child can be monitored.
When the child is quiet for the specified time, he or she can leave the room.
a.
b.
c.
d.
e.
ANS: B, C, D
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.
DIF: Cognitive Level: Apply
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
behaviors related to the divorce. The nurse is correct when explaining that the parents should
be prepared for which types of behaviors? (Select all that apply.)
a. Displaying fears of abandonment
b. Verbalizing that he or she “is the reason for the divorce”
c. Displaying fear regarding the future
d. Ability to disengage from the divorce proceedings
e. Engaging in fantasy to understand the divorce
ANS: A, B, E
A child 3 to 5 years of age (preschool) may display fears of abandonment, verbalize feelings
that he or she is the reason for the divorce, and engage in fantasy to understand the divorce.
He or she would not be displaying fear regarding the future until school age, and the ability to
disengage from the divorce proceedings would be characteristic of an adolescent.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Teaching and Learning
Chapter 03: Developmental and Genetic Influences on Child Health Promotion
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. An infant gains head control before sitting unassisted. The nurse recognizes that this is which
type of development?
Cephalocaudal
Proximodistal
Mass to specific
Sequential
a.
b.
c.
d.
ANS: A
The pattern of development that is head-to-tail, or cephalocaudal, direction is described by an
infant’s ability to gain head control before sitting unassisted. The head end of the organism
develops first and is large and complex, whereas the lower end is smaller and simpler, and
development takes place at a later time. Proximodistal, or near to far, is another pattern of
development. Limb buds develop before fingers and toes. Postnatally, the child has control of
the shoulder before achieving mastery of the hands. Mass to specific is not a specific pattern
of development. In all dimensions of growth, a definite, sequential pattern is followed.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. An infant who weighs 7 pounds (3.18 kilograms) at birth would be expected to weigh how
many pounds/kilograms at age 1 year?
15 lbs/6.80 kg
17 lbs/7.71 kg
19 lbs/8.62 kg
21 lbs/9.53 kg
a.
b.
c.
d.
ANS: D
In general, birth weight triples by the end of the first year of life. For an infant who was 7
pounds at birth, 21 pounds would be the anticipated weight at the first birthday; 14, 16, or 18
pounds is below what would be expected for an infant with a birth weight of 7 pounds.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. By Which age does birth length usually double?
a. 1 year
b. 2 years
c. 4 years
d. 6 years
ANS: C
Linear growth or height occurs almost entirely as a result of skeletal growth and is considered
a stable measurement of general growth. On average, most children have doubled their birth
length at age 4 years. One and 2 years are too young for doubling of length. Most children
will have achieved the doubling by age 4 years.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. How is a 5-year-old child’s skeletal age best determined?
a. Assessment of dentition
b. Assessment of height over time
c. Facial bone development
d. Radiographs of the hand and wrist
ANS: D
The most accurate measure of skeletal age is radiologic examinations of the growth plates.
These are the epiphyseal cartilage plates. Radiographs of the hand and wrist provide the most
useful screening to determine skeletal age. Age of tooth eruption has considerable variation in
children. It would not be a good determinant of skeletal age. Assessment of height over time
will provide a record of the child’s height but not skeletal age. Facial bone development will
not reflect the child’s skeletal age, which is determined by radiographic assessment.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Trauma to which site can result in a growth problem for children’s long bones?
a. Matrix
b. Connective tissue
c. Calcified cartilage
d. Epiphyseal cartilage plate
ANS: D
The epiphyseal cartilage plate is the area of active growth. Bone injury at the epiphyseal plate
can significantly affect subsequent growth and development. Trauma or infection can result in
deformity. The matrix, connective tissue, and calcified cartilage are not areas of active growth.
Trauma in these sites will not result in growth problems for the long bones.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which statement is accurate about lymphoid tissue?
a. It reaches adult size by age 1 year.
b. It quits growing by 6 years of age.
c. Is poorly developed at birth.
d. Is twice the adult size by ages 10 to 12 years.
ANS: D
Lymphoid tissue continues growing until it reaches maximal development at ages 10 to 12
years, which is twice its adult size. A rapid decline in size occurs until it reaches adult size by
the end of adolescence. The tissue reaches adult size at 6 years of age but continues to grow.
The tissue is well developed at birth.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which statement is true about the basal metabolic rate (BMR) in children?
a.
b.
c.
d.
It is reduced by fever.
It is lowest in newborn infants.
It increases with age of child.
It is slightly higher in boys than in girls at all ages.
ANS: D
The BMR is the rate of metabolism when the body is at rest. At all ages, the rate is slightly
higher in boys than in girls. The rate is increased by fever. The BMR is highest in infancy and
then closely relates to the proportion of surface area to body mass. As the child grows, the
proportion decreases progressively to maturity.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
8. A mother reports that her 6-year-old child is highly active, irregular in habits and adapts
slowly to new routines, people, or situations. How would the nurse chart this type of
temperament?
a. Easy
b. Difficult
c. Slow-to-warm-up
d. Fast-to-warm-up
ANS: B
Being highly active, irritable, irregular in habits, and adapting slowly to new routines, people,
or situations is a description of difficult children, which compose about 10% of the
population. Negative withdrawal responses are typical of this type of child, who requires a
more structured environment. Mood expressions are usually intense and primarily negative.
These children exhibit frequent periods of crying and often violent tantrums. Easy children are
even tempered, regular, and predictable in their habits. They are open and adaptable to change.
Approximately 40% of children fit this description. Slow-to-warm-up children typically react
negatively and with mild intensity to new stimuli and adapt slowly with repeated contact.
Approximately 10% of children fit this description. “Fast-to-warm-up” is not one of the
categories identified.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
9. A 12-year-old child enjoys collecting stamps, playing soccer, and participating in Boy Scout
activities. The nurse recognizes that the child is displaying which developmental task?
Identity
Industry
Integrity
Intimacy
a.
b.
c.
d.
ANS: B
Industry is engaging in tasks that can be carried through to completion, learning to compete
and cooperate with others, and learning rules. Industry is the developmental task characteristic
of the school-age child. Identity is the developmental task of adolescence. Integrity and
intimacy are not developmental tasks of childhood.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. 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
selfishness.
self-centeredness.
preferring to play alone.
unable to put self in another’s place.
a.
b.
c.
d.
ANS: D
According to Piaget, children ages 2 to 7 years are in the preoperational stage of development.
Children interpret objects and events not in terms of their general properties but in terms of
their relationships or their use to them. This egocentrism does not allow children of this age to
put themselves in another’s place. Selfishness, self-centeredness, and preferring to play alone
do not describe the concept of egocentricity.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Because a visitor arrives at a daycare center during lunchtime, preschool children think that
every time they have lunch a visitor will arrive. Which preoperational characteristic is being
displayed?
a. Egocentrism
b. Conservation
c. Intuitive reasoning
d. Transductive reasoning
ANS: D
Transductive reasoning is when two events occur together, they cause each other. The
expectation that every time lunch is served a visitor will arrive is descriptive of transductive
reasoning. Egocentrism is the inability to see things from any perspective than their own.
Intuitive reasoning (e.g., the stars have to go to bed just as they do) is predominantly
egocentric thought. Conservation (able to realize that physical factors such as volume, weight,
and number remain the same even though outward appearances are changed) does not occur
until school age.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
12. Which statement is most characteristic of a preschooler’s stage of moral development
according to Kohlberg?
Obeying the rules of correct behavior is important.
Showing respect for authority is important behavior.
Behavior that pleases others is considered good.
Actions are determined as good or bad in terms of their consequences.
a.
b.
c.
d.
ANS: D
Preschoolers are most likely to exhibit characteristics of Kohlberg’s preconventional level of
moral development. During this stage, they are culturally oriented to labels of good or bad,
right or wrong. Children integrate these concepts based on the physical or pleasurable
consequences of their actions. Obeying the rules of correct behavior, showing respect for
authority, and engaging in behavior that pleases others are characteristics of Kohlberg’s
conventional level of moral development.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. A school nurse notes that school-age children generally obey the rules at school and attributes
this to which stage of moral development?
Preconventional
Conventional
Postconventional
Undifferentiated
Sense-pleasure
a.
b.
c.
d.
e.
ANS: D
Conventional stage of moral development is described as obeying the rules, doing one’s duty,
showing respect for authority, and maintaining the social order. This stage is characteristic of
school-age children’s behavior. The preconventional stage is characteristic of the toddler and
preschool age. At this stage, the child has no concept of the basic moral order that supports
being good or bad. The postconventional level is characteristic of an adolescent and occurs at
the formal stage of operation. Undifferentiated describes an infant’s understanding of moral
development.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
14. In which type of play are children engaged in similar or identical activity, without
organization, division of labor, or mutual goal?
Solitary
Parallel
Associative
Cooperative
a.
b.
c.
d.
ANS: C
In associative play, no group goal is present. Each child acts according to his or her own
wishes. Although the children may be involved in similar activities, no organization, division
of labor, leadership assignment, or mutual goal exists. Solitary play describes children playing
alone with toys different from those used by other children in the same area. Parallel play
describes children playing independently but being among other children. Cooperative play is
organized. Children play in a group with other children who play in activities for a common
goal.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A nurse is planning play activities for school-age children. Which type of a play activity
would the nurse plan?
a.
b.
c.
d.
Solitary
Parallel
Associative
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. Which would the nurse consider when discussing language development with parents of
toddlers?
Sentences by toddlers include adverbs and adjectives.
The toddler expresses himself or herself with verbs or combination words.
The toddler uses simple sentences.
Pronouns are used frequently by the toddler.
a.
b.
c.
d.
ANS: B
The first parts of speech used are nouns, sometimes verbs (e.g., “go”), and combination words
(e.g., “bye-bye”). Responses are usually structurally incomplete during the toddler period. The
preschool child begins to use adjectives and adverbs to qualify nouns followed by adverbs to
qualify nouns and verbs. Pronouns are not added until the later preschool years. By the time
children enter school, they are able to use simple, structurally complete sentences that average
five to seven words.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Turner syndrome is suspected in an adolescent girl with short stature. Which is the cause of
this syndrome?
a. Absence of one of the X chromosomes
b. Presence of an incomplete Y chromosome
c. Precocious puberty in an otherwise healthy child
d. Excess production of both androgens and estrogens
ANS: A
Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have
this disorder have one X chromosome missing from all cells. No Y chromosome is present in
individuals with Turner syndrome. This young woman has 45 rather than 46 chromosomes.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. When the parents of a newborn ask the nurse about the causative factor in clubfoot, which
response is appropriate?
a. A result of abnormal organizational cells
b. A breakdown of previously normal tissue
c. Condition is often caused by uterine constraint
d. Fibrous bands of amnion wrapped around the leg
ANS: C
Club foot is an example of a deformation often caused by uterine constraint. Disruptions result
from the breakdown of previously normal tissue. Congenital amputations caused by amniotic
bands (fibrous strands of amnion that wrap around different body parts during development)
are examples of disruption anomalies. Dysplasias result from abnormal organization of cells
into a particular tissue type.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The first term pregnant adolescent has understood the nurse’s teaching if she makes which
statement? (Select all that apply.)
“I will be able to continue taking isotretinoin (Accutane) for my acne.”
“I will seek help immediately if I have a fever.”
“I should avoid any alcoholic beverages.”
“I can continue my phenytoin (Dilantin) dosage.”
“I will ensure my vaccinations are current and talk to my physician if they are
not”.
a.
b.
c.
d.
e.
ANS: B, C, E
Adverse intrauterine effects not attributable to genetic factors include infectious agents such
as rubella and chemical agents such as ethyl alcohol. Rubella is a routine childhood
immunization, so the adolescent should talk to her physician if vaccinations are not current.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the sequence of cephalocaudal development that the nurse expects to find in the
infant. Begin with the first development expected, sequencing to the final. Provide answers
using lowercase letters separated by commas (e.g., A, B, C, D).
a. Crawl
b. Sit unsupported
c. Lift head when prone
d. Gain complete head control
e. Walk
ANS:
C, D, B, A, E
Cephalocaudal development is head-to-tail. Infants achieve structural control of the head
before they have control of their trunks and extremities, they lift their head while prone,
obtain complete head control, sit unsupported, crawl, and walk sequentially.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 04: Communication and Physical Assessment of the Child and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which strategy by the nurse is most likely to encourage parents to talk about their feelings
related to their child’s illness?
Expressing sympathy.
Asking direct questions.
Asking open-ended questions.
Avoiding periods of silence.
a.
b.
c.
d.
ANS: C
Closed-ended questions should be avoided when attempting to elicit parents’ feelings. Openended questions require the parent to respond with more than a brief answer. Sympathy is
having feelings or emotions in common with another person rather than understanding those
feelings (empathy). Sympathy is not therapeutic in helping the relationship. Direct questions
may obtain limited information. In addition, the parent may consider them threatening.
Silence can be an effective interviewing tool. It allows sharing of feelings in which two or
more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts
and feelings and search for responses to questions.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
2. Which is the single most important factor to consider when communicating with children?
a. Physical condition
b. Nonverbal behaviors
c. Presence or absence of a parent
d. Developmental level of language
ANS: D
The nurse must be aware of the child’s developmental stage to engage in effective
communication. The use of both verbal and nonverbal communication should be appropriate
to the developmental level. Although the child’s physical condition is a consideration,
developmental level is much more important. The parents’ presence is important when
communicating with young children but may be detrimental when speaking with adolescents.
Nonverbal behaviors will vary in importance, based on the child’s developmental level.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
3. Which is an important consideration for the nurse who is communicating directly to a young
child?
Speak loudly, clearly, and directly.
Use transition objects, such as a doll.
Approach rapidly with a broad smile.
Initiate contact with child when parent is not present.
a.
b.
c.
d.
ANS: B
Using a transition object allows the young child an opportunity to evaluate an unfamiliar
person (the nurse). This will facilitate communication with a child this age. Speaking in this
manner will tend to increase anxiety in very young children. The nurse must be honest with
the child. Attempts at deception will lead to a lack of trust. Whenever possible, the parent
should be present for interactions with young children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
4. A nurse is assigned to four children of different ages. In which age group would the nurse
understand that body integrity is a concern?
Toddler
Preschooler
School-age child
Adolescent
a.
b.
c.
d.
ANS: C
School-age children have a heightened concern about body integrity. They place importance
and value on their bodies and are oversensitive to anything that constitutes a threat or
suggestion of injury. Body integrity is not as important a concern to toddlers, preschoolers, or
adolescents.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which
technique might be most helpful?
Suggest that the child keep a diary.
Suggest that the parent read fairy tales to the child.
Ask the parent if the child is always stubborn and uncommunicative.
Ask the child to draw a picture.
a.
b.
c.
d.
ANS: D
Drawing is one of the most valuable forms of communication and tell a great deal about the
child because they are projections of their inner self. A diary is appropriate for older children.
Reading a fairy tale to the child by the parent is not likely to assist in the nurse/child
communication. The nurse is not displaying patience by asking the parent if the child is
always stubborn and uncommunicative.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
6. The nurse is taking a health history on an adolescent. Which best describes how the chief
complaint would be determined?
a. Ask for detailed listing of symptoms.
b. Ask adolescent, “Why did you come here today?”
c. Use Which adolescent says to determine, in correct medical terminology, Which
the problem is.
d. Interview parent away from adolescent to determine chief complaint.
ANS: B
The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital.
Because the adolescent is the focus of the history, this is an appropriate way to determine the
chief complaint. A detailed listing of symptoms will make it difficult to determine the chief
complaint. The adolescent should be prompted to tell which symptom caused him to seek help
at this time. The chief complaint is usually written in the words that the parent or adolescent
uses to describe the reason for seeking help. The parent and adolescent may be interviewed
separately, but the nurse should determine the reason the adolescent is seeking attention at this
time.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine
whether she is sexually active?
Ask her, “Are you sexually active?”
Ask her, “Are you having sex with anyone?”
Ask her, “Are you having sex with a boyfriend?”
Ask both the girl and her parent whether she is sexually active.
a.
b.
c.
d.
ANS: B
Asking the adolescent girl whether she is having sex with anyone is a direct question that is
well understood. The phrase sexually active is broadly defined and may not provide specific
information to the nurse to provide necessary care. The word anyone is preferred to using
gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation
may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity
should occur when the adolescent is alone.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet
consists mainly of vegetables, legumes, and starches. How would the nurse assess this diet?
Indicates they live in poverty
Is lacking in protein
May provide sufficient amino acids
Should be enriched with meat and milk
a.
b.
c.
d.
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. Combinations of foods contain the essential amino
acids necessary for growth. A dietary assessment should be done, but many vegetarian diets
are sufficient for growth.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Which following parameters correlates best with measurements of the body’s total protein
stores?
a. Height
b. Weight
c. Skinfold thickness
d. Upper arm circumference
ANS: D
Upper arm circumference is correlated with measurements of total muscle mass. Muscle
serves as the body’s major protein reserve and is considered an index of the body’s protein
stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional
status. Skinfold thickness is a measurement of the body’s fat content.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. The nurse accurately relates which body mass index (BMI)-for-age percentile as overweight?
a. 10th percentile
b. 9th percentile
c. 85th percentile
d. 95th percentile
ANS: C
Children who have BMI-for-age greater than or equal to the 85th percentile and less than the
95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are
within normal limits. Children who are greater than or equal to the 95th percentile are
considered overweight.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Which is the earliest age at which a satisfactory radial pulse can be taken in children?
a. 1 year
b. 2 years
c. 3 years
d. 6 years
ANS: B
Satisfactory radial pulses can be used in children older than 2 years. In infants and young
children, the apical pulse is more reliable. The apical pulse can be used for assessment at these
ages.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. When palpating the child’s cervical lymph nodes, the nurse notes that they are tender,
enlarged, and warm. Which is the best explanation for this?
A cancerous lesion
Local scalp infection common in children
Mild otitis media
Infection or inflammation close to the site
a.
b.
c.
d.
ANS: D
Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate
infection or inflammation close to their location. Tender lymph nodes are not usually
indicative of cancer. A scalp infection would usually not cause inflamed lymph nodes. The
lymph nodes close to the site of inflammation or infection would be inflamed.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. The nurse has just started assessing a young child who is febrile and appears very ill. There is
hyperextension of the child’s head (opisthotonos) with pain on flexion. Which is the most
appropriate action?
a. Refer for immediate medical evaluation.
b. Continue assessment to determine cause of neck pain.
c. Ask parent when neck was injured.
d. Record “head lag” on assessment record, and continue assessment of child.
ANS: A
Hyperextension of the child’s head with pain on flexion is indicative of meningeal irritation
and needs immediate evaluation; it is not descriptive of head lag. The pain is indicative of
meningeal irritation. No indication of injury is present.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
14. At which age would the nurse expect the anterior fontanel to close?
a. 2 months
b. 2 to 4 months
c. 6 to 8 months
d. 12 to 18 months
ANS: D
The anterior fontanel normally closes between ages 12 and 18 months. Two to 8 months is too
early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if
it closes between ages 2 and 8 months, the child should be referred for further evaluation.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform
red reflex in both eyes. How would the nurse interpret this finding?
Normal finding
Abnormal finding, so child needs referral to ophthalmologist
Sign of possible visual defect, so child needs vision screening
Sign of small hemorrhages, which will usually resolve spontaneously
a.
b.
c.
d.
ANS: A
A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects
of the cornea, aqueous chamber, lens, and vitreous chamber.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
16. Parents of a newborn are concerned because the infant’s eyes often “look crossed” when the
infant is looking at an object. The nurse’s response is that this is normal based on the
knowledge that binocularity is normally present by which age?
a. 1 to 2 weeks
b. 1 to 2 months
c. 3 to 4 weeks
d. 3 to 4 months
ANS: D
Binocularity is usually achieved by ages 3 to 4 months. 1 month is too young. If binocularity
is not achieved by ages 6 to 12 months, the child must be observed for strabismus.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Which is an appropriate screening test for hearing that can be administered by the nurse to a
5-year-old child?
Auditory brainstem response
Behavioral audiometry
Pure tone audiometry
Eliciting the startle reflex
a.
b.
c.
d.
ANS: C
Conventional audiometry is a behavioral test that measures auditory thresholds in response to
speech and frequency-specific stimuli presented through earphones. The Rinne and Weber
tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Which 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?
Vesicular
Bronchial
Adventitious
Bronchovesicular
a.
b.
c.
d.
ANS: A
Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the
upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are
heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not
usually heard over the chest. These sounds occur in addition to normal or abnormal breath
sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper
intrascapular regions where trachea and bronchi bifurcate.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
19. How does the nurse assess a child’s capillary refill time?
a. Inspecting the chest
b. Auscultating the heart
c. Palpating the apical pulse
d. Pressing the pad of the fingertip
ANS: D
Capillary refill time is assessed by pressing lightly on the skin to produce blanching, and then
noting the amount of time it takes for the blanched area to refill. Inspecting the chest,
auscultating the heart, and palpating the apical pulse will not provide an assessment of
capillary refill time.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
20. A nurse is performing an otoscopic exam on a school-age child. Which direction would the
nurse pull the pinna for a child this age?
Up and back
Down and back
Straight back
Straight up
a.
b.
c.
d.
ANS: A
In children older than 3 years, the ear canal curves downward and forward. As a result, when
performing an otoscopic exam, the nurse will pull the pinna up and back before inserting the
otoscope.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Caring
MSC: Area of Client Needs: Physiological Integrity: Reduction of Risk Potential
21. During examination of a toddler’s extremities, the nurse notes that the child is bowlegged.
Which would the nurse recognize regarding this finding?
Abnormal and requires further investigation
Abnormal unless it occurs in conjunction with knock-knee
Normal if the condition is unilateral or asymmetric
Normal because the lower back and leg muscles are not yet well developed
a.
b.
c.
d.
ANS: D
Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk. It
usually persists until all their lower back and leg muscles are well developed. Further
evaluation is needed if it persists beyond ages 2 to 3 years, especially in African-American
children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Health Promotion and Maintenance
22. A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do
the “finger-to-nose” test. Which is the nurse testing for?
Deep tendon reflexes
Cerebellar function
Sensory discrimination
Ability to follow directions
a.
b.
c.
d.
ANS: B
The finger-to-nose test is an indication of cerebellar function. This test checks balance and
coordination. Each deep tendon reflex is tested separately. Each sense is tested separately.
Although this test enables the nurse to evaluate the child’s ability to follow directions, it is
used primarily for cerebellar function.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which of the following data would be included in a health history? (Select all that apply.)
a. Review of systems
b. Medical insurance carrier
c. Past medical history
d. Nutritional assessment
e. Family medical history
ANS: A, C, D, E
The review of systems, sexual history, nutritional assessment, and family medical history are
part of the health history. Physical assessment and growth measurements are components of
the physical examination.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. 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 would the nurse include when
using an interpreter? (Select all that apply.)
a. Elicit one answer at a time.
b. Interrupt the interpreter if the response from the family is lengthy.
c. Comments to the interpreter about the family should be made in English.
d. Arrange for the family to speak with the same interpreter, if possible.
e. Introduce the interpreter to the family.
ANS: A, D, E
When using an interpreter, the nurse should pose questions to elicit only one answer at a time,
such as: “Do you have pain?” rather than “Do you have any pain, tiredness, or loss of
appetite?” Refrain from interrupting family members and the interpreter while they are
conversing. Introduce the interpreter to family and allow some time before the interview for
them to become acquainted. Refrain from interrupting family members and the interpreter
while they are conversing. Avoid commenting to the interpreter about family members
because they may understand some English.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. What is the correct sequence used by experienced examiners when performing an abdominal
assessment? Begin with the first technique and end with the last. Provide answer using
lowercase letters separated by commas (e.g., A, B, C, D).
a. Auscultation
b. Palpation
c. Inspection
d. Percussion
ANS:
C, A, D, B
The correct order of abdominal examination is inspection, auscultation, percussion, and
palpation. Palpation is always performed last because it may distort the normal abdominal
sounds.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 05: Pain Assessment and Management in Children
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which
pain assessment tool should the nurse use to assess this child for the presence of pain?
FACES pain rating tool
Numeric scale
Oucher scale
FLACC tool
a.
b.
c.
d.
ANS: D
A behavioral pain tool should be used when the child is preverbal or doesn’t have the
language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool
should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all selfreport pain rating tools. Self-report measures are not sufficiently valid for children younger
than 3 years of age because many are not able to accurately self-report their pain.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. While gathering a history, the school-age child reports migraines every 2 or 3 months for the
last year. The nurse documents this as which type of pain?
Acute
Chronic
Recurrent
Subacute
a.
b.
c.
d.
ANS: C
Pain that is episodic and reoccurs is defined as recurrent pain. The time frame within which
episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine
headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain.
Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily
basis, for more than 3 months. Subacute is not a term for documenting type of pain.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Physiologic Integrity
3. Nonpharmacologic strategies for pain management
a. may reduce pain perception.
b. make pharmacologic strategies unnecessary.
c. usually take too long to implement.
d. trick children into believing they do not have pain.
ANS: A
Nonpharmacologic techniques provide coping strategies that may help reduce pain perception,
make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics.
Nonpharmacologic techniques should be learned before the pain occurs. With severe pain, it is
best to use both pharmacologic and nonpharmacologic measures for pain control. The
nonpharmacologic strategy should be matched with the child’s pain severity and taught to the
child before the onset of the painful experience. Some of the techniques may facilitate the
child’s experience with mild pain, but the child will still know the discomfort was present.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
4. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the
immediate postoperative period?
Meloxicam
Morphine
Methadone
Meperidine
a.
b.
c.
d.
ANS: B
The most commonly prescribed medications for PCA are morphine, hydromorphone, and
fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in
parenteral form in the United States. Meperidine is not used for continuous and extended pain
relief.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
5. Fentanyl and midazolam (Versed) are given before débridement of a child’s burn wounds.
Which is the rationale for administration of these medications?
Promote healing
Prevent infection
Provide pain relief
Limit amount of débridement that will be necessary
a.
b.
c.
d.
ANS: C
Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control
procedural pain in children with burns. These drugs are for sedation and pain control, not
healing, preventing infection, or limiting the amount of débridement.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
6. Nitrous oxide is being administered to a child with extensive burn injuries. Which is the
purpose of this medication?
Promote healing
Prevent infection
Provide anesthesia
Improve urinary output
a.
b.
c.
d.
ANS: C
The use of short-acting anesthetic agents, such as propofol and nitrous oxide, has proven
beneficial in eliminating procedural pain. Nitrous oxide is an anesthetic agent.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. A lumbar puncture is needed on a school-age child. What should the nurse apply to provide
the most appropriate analgesia during this procedure? (Select all that apply.)
Synera (lidocaine and tetracaine)
Transdermal fentanyl (Duragesic) patch
EMLA (eutectic mixture of local anesthetics)
LMX4 (Lidocaine)
Oralet (oral transmucosal fentanyl)
a.
b.
c.
d.
e.
ANS: A, C, D
EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure.
It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides
skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on
the wound for suturing. Transdermal fentanyl patches are useful for continuous pain control,
not rapid pain control. For maximal effectiveness, EMLA must be applied approximately 60
minutes in advance.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse recognizes which physiologic responses as a manifestation of acute pain in a neonate?
(Select all that apply.)
Diaphoresis
Increased heart rate
Increased SaO2
Increased blood pressure
Decreased muscle tone
a.
b.
c.
d.
e.
ANS: A, B, D
The physiologic responses that indicate pain in neonates are increased heart rate, increased
blood pressure, rapid, shallow respirations, decreased arterial oxygen saturation (SaO2), pallor
or flushing, diaphoresis, and palmar sweating.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
3. A nurse is monitoring a patient for side effects associated with opioid analgesics. For which
side effects should the nurse expect to monitor? (Select all that apply.)
Constipation
Diarrhea
Hypertension
Pruritus
a.
b.
c.
d.
e. Respiratory depression
ANS: A, B, D, E
Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation
may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
4. Which recommendations should a nurse make to an adolescent patient to manage constipation
related to opioid analgesic administration? (Select all that apply.)
Bran cereal
Decrease fluid intake
Prune juice
Cheese
Physical activity
a.
b.
c.
d.
e.
ANS: A, C, E
To manage the side effect of constipation caused by opioids, fluids should be increased, and
bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a
nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause
constipation so it should not be recommended.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
5. The nurse should prepare to monitor the patient for which side effects of an opioid epidural
catheter? (Select all that apply.)
Urinary retention
Nausea
Itching
Respiratory depression
a.
b.
c.
d.
ANS: A, B, C
Respiratory depression, nausea, itching, and urinary retention are dose-related side effects
from an epidural opioid. Urinary retention, not urinary frequency, would be seen.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
6. A patient on an intravenous opioid analgesic has become apneic. The nurse should implement
which interventions? (Select all that apply.)
Place the patient on continuous pulse oximetry to assess SaO2.
Administer the prescribed naloxone (Narcan) dose by slow IV push.
Leave the bedside to notify the physician.
Prepare to calm the child as analgesia is reversed.
Give scheduled opioid along with naloxone (Narcan).
a.
b.
c.
d.
e.
ANS: A, B, D
The Narcan prescribed dose should be given, first by slow IV push every 2 minutes until
effect is obtained. The second intervention should be assessment of the patient’s SaO2 status.
Oxygen should be made available and administered if the SaO2 status indicates hypoxemia.
Last, the child should be calmed as the analgesia is reversed.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
COMPLETION
1. A dose of oxycodone (OxyContin) 2 mg/kg has been ordered for a child weighing 33 lb. How
many milligrams of OxyContin should the nurse administer? ______ (Record your answer as
a whole number.)
ANS:
30
The child’s weight is divided by 2.2 to get the weight in kilograms. Kilograms in weight are
then multiplied by the prescribed 2 mg. 33 lb/2.2 = 15 kg. 15 kg  2 mg = 30 mg.
DIF: Cognitive Level: Apply
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
Face
No
Occasional
Frequent to
particular grimace or
constant
expression frown,
frown,
or smile
withdrawn,
clenched
disinterested jaw,
quivering
chin
Legs
Normal
Uneasy,
Kicking, or
position or restless, tense legs drawn
relaxed
up
Activity
Lying
Squirming,
Arched,
quietly,
shifting back rigid, or
normal
and forth, tense jerking
position,
Cry
moves easily
No cry
Moans or
(awake or whimpers,
asleep)
occasional
complaint
Consolability Content,
relaxed
Reassured by
occasional
touching,
hugging, or
talking to;
distractible
Crying
steadily,
screams or
sobs,
frequent
complaints
Difficult to
console or
comfort
Because the child has a grimace and is squirming and tense, 2 total points are given. Relaxed
legs, no cry, and content and relaxed consolability get 0 points.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 06: Childhood Communicable and Infectious Diseases
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which nursing consideration is important when caring for a child with impetigo?
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 when caring for an infected child.
d. Implement airborne precautions.
ANS: C
A major nursing consideration related to bacterial skin infections, such as impetigo
contagiosa, is to prevent the spread of the infection and complications. This is done by
thorough hand washing before and after contact with the affected child. Corticosteroids are
not indicated in bacterial infections. Dressings are usually not indicated. The undermined skin,
crusts, and debris are carefully removed after softening with moist compresses. A Wood lamp
is used to detect fluorescent materials in the skin and hair. It is used in certain disease states,
such as tinea capitis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse would expect to assess which causative agent in a child with warts?
a. Bacteria
b. Fungus
c. Parasite
d. Virus
ANS: D
Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and
parasites does not result in warts.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. Shingles are caused by which virus?
a. Varicella zoster virus
b. Cytomegalovirus
c. Parvovirus
d. Coxsackie virus
ANS: A
The varicella zoster virus causes two distinct diseases: varicella and herpes zoster or shingles.
Cytomegalovirus is a common virus however, it can cause organ damage in newborns born
with this CMV with the most common being hearing loss. Human parvovirus infects and lyses
red blood cell precursors, thus interrupting the production of red blood cells. Coxsackie virus
is a nonpolio enterovirus and can cause the hand-foot- and- mouth disease.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
4. Which causes Enterobius vermicularis (pinworm)?
a. Virus
b. Parasite
c. Allergic reaction
d. Bacterial infection
ANS: B
Enterobiasis or pinworm infection is a common, contagious, parasitic infestation found mainly
in children. Severe itching is caused by the pinworm. Bacterial and viral microorganisms are
not associated with Enterobiasis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
5. Parents tell the nurse that their child keeps scratching the areas where he has bed bugs. The
nurse’s response would be based on which statement?
The parasitic bugs do not cause itching and needs further investigation.
Scratching the lesions will not cause a problem.
Scratching the lesions will cause the bed bugs to spread.
Scratching the lesions may cause them to become secondarily infected.
a.
b.
c.
d.
ANS: D
Intense urticaria may occur with bed bugs which may cause secondary infections from itching.
There is no evidence that scratching will cause the bed bugs to spread.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Airborne isolation is required for a child who is hospitalized with
a. mumps.
b. chickenpox.
c. exanthema subitum (roseola).
d. erythema infectiosum (fifth disease).
ANS: B
Chickenpox is communicable through direct contact, droplet spread, and contaminated
objects. Mumps is transmitted from direct contact with saliva of infected person and is most
communicable before onset of swelling. The transmission and source of the viral infection
exanthema subitum (roseola) is unknown. Erythema infectiosum (fifth disease) is
communicable before onset of symptoms.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment
7. Acyclovir (Zovirax) is given to children with chickenpox to
a. minimize scarring.
b. decrease the number of lesions.
c. prevent aplastic anemia.
d. prevent spread of the disease.
ANS: B
Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching,
lethargy, and anorexia. Treating pruritus and discouraging itching minimize scarring. Aplastic
anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents
spread of disease.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
8. Vitamin A supplementation may be recommended for the young child who has which disease?
a. Mumps
b. Rubella
c. Measles (rubeola)
d. Erythema infectiosum
ANS: C
Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated
with analgesics for pain and antipyretics for fever. Rubella is treated similarly to mumps.
Erythema infectiosum is treated similarly to mumps and rubella.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
9. In which 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
10. Which is a common childhood communicable disease that may cause severe defects in the
fetus when it occurs during pregnancy?
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
11. Which is the causative agent of scarlet fever?
a. Enteroviruses
b. Corynebacterium organisms
c. Scarlet fever virus
d. Group A -hemolytic streptococci (GABHS)
ANS: D
GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications.
Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
12. A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with
purulent drainage and crusting of the eyelids, especially on awakening. These manifestations
suggest
a. viral conjunctivitis.
b. allergic conjunctivitis.
c. bacterial conjunctivitis.
d. conjunctivitis caused by foreign body.
ANS: C
Bacterial conjunctivitis has these symptoms. Viral or allergic conjunctivitis has watery
drainage. Foreign body causes tearing and pain, and usually only one eye is affected.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity
13. Which is an important nursing consideration when caring for a child with herpetic
gingivostomatitis (HGS)?
Apply topical anesthetics before eating.
Drink from a cup, not a straw.
Wait to brush teeth until lesions are sufficiently healed.
Explain to parents how this is sexually transmitted.
a.
b.
c.
d.
ANS: A
Treatment for HGS is aimed at relief of pain. Drinking bland fluids through a straw helps
avoid painful lesions. Mouth care is encouraged with a soft toothbrush. HGS is usually caused
by herpes simplex virus type 1, which is not associated with sexual transmission.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
14. A parent has asked the nurse about how her child can be tested for pinworms. The nurse
responds by stating that which is the most common test for diagnosing pinworms in a child?
Lower gastrointestinal (GI) series
Three stool specimens, at intervals of 4 days
Observation for presence of worms after child defecates
Tape test prior to defecating
a.
b.
c.
d.
ANS: D
Laboratory examination of substances containing the worm, its larvae, or ova can identify the
organism. Most are identified by examining fecal smears from the stools of persons suspected
of harboring the parasite. Fresh specimens are best for revealing parasites or larvae. Lower GI
series is not helpful for diagnosing enterobiasis. Stool specimens are not necessary to
diagnose pinworms. Worms will not be visible after child defecates.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
15. A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication
would the nurse expect to be prescribed?
Metronidazole (Flagyl)
Amoxicillin clavulanate (Augmentin)
Clarithromycin (Biaxin)
Prednisone (Orapred)
a.
b.
c.
d.
ANS: A
The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole
(Tindamax), and nitazoxanide (Alinia). These are classified as antifungals. Amoxicillin and
clarithromycin are antibiotics that treat bacterial infections. Prednisone is a steroid and is used
as an anti-inflammatory medication.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
16. A mother tells the nurse that she does not want her infant immunized because of the
discomfort associated with injections. Which would the nurse explain?
This cannot be prevented.
Infants do not feel pain as adults do.
This is not a good reason for refusing immunizations.
A topical anesthetic, EMLA, can be applied before injections are given.
a.
b.
c.
d.
ANS: D
Several topical anesthetic agents can be used to minimize the discomfort associated with
immunization injections. These include EMLA (eutectic mixture of local anesthetic) and
vapor coolant sprays. Pain associated with many procedures can be prevented and minimized
by using the principles of atraumatic care. With preparation, the injection site can be properly
anesthetized to decrease the amount of pain felt by the infant. Infants have the neural
pathways to feel pain. Numerous research studies have indicated that infants perceive and
react to pain in the same manner as do children and adults. The mother should be allowed to
discuss her concerns and the alternatives available. This is part of the informed consent
process.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is taking care of a 7-year-old child with severe herpetic gingivostomatitis (HGS).
Which prescribed medication would the nurse expect to be included in the treatment plan?
(Select all that apply.)
a. Corticosteroids
b. Oral metronidazole
c. Oral antiviral agent
d. Systemic antibiotic
e. Topical anesthetic
ANS: C, E
Topical anesthetics are used as needed to provide pain relief. Treatment for children with
severe cases may include antiviral agents such as acyclovir. HGS is a virus therefore
antibiotics such as metronidazole are not effective. Corticosteroids are not a standard
treatment for HGS.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Caring
MSC: Area of Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Chapter 07: Health Promotion of the Newborn and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which is a function of brown adipose tissue (BAT) in the newborn?
a. Provides ready source of calories in the newborn period
b. Insulates the body against lowered environmental temperature
c. Protects the newborn from injury during the birth process
d. Generates heat for distribution to other parts of body
ANS: D
Brown fat is a unique source of heat for the newborn. It has a larger content of mitochondrial
cytochromes and a greater capacity for heat production through intensified metabolic activity
than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of
the body by the blood. It is effective in heat production only. The newborn has a thin layer of
subcutaneous fat, which does not provide for conservation of heat. Brown fat is located in
superficial areas such as between the scapulae, around the neck, in the axillae, and behind the
sternum. These areas would not protect the newborn from injury during the birth process.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. In full term newborns, the first meconium stool occurs within how many hours of birth?
a. 6 to 8
b. 8 to 12
c. 12 to 24
d. 24 to 48
ANS: D
The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to
7 days in very low birth weight newborns. Although it may occur earlier, the expected range is
the first 24 to 48 hours of life.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is doing an assessment on a newborn. Which is characteristic of a newborn’s vision at
birth and an expected finding during the assessment?
Ciliary muscles are mature.
Blink reflex is absent.
Tear glands function.
Pupils react to light.
a.
b.
c.
d.
ANS: D
Although at birth the eye is still structurally incomplete, the pupils do react to light. The
ciliary muscles are immature, limiting the eyes’ ability to focus on an object for any length of
time. The blink reflex is responsive to minimal stimulus. The tear glands do not begin to
function until ages 2 to 4 weeks.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. The Apgar score of a newborn 5 minutes after birth is 8. Which is the nurse’s best
interpretation of this?
Resuscitation is likely to be needed.
Adjustment to extrauterine life is adequate.
Additional scoring in 5 more minutes is needed.
Maternal sedation or analgesia contributed to the low score.
a.
b.
c.
d.
ANS: B
The Apgar reflects the newborn’s status in five areas: heart rate, respiratory effort, muscle
tone, reflex irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting
to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 6 indicate
moderate difficulty. The Apgar score is not used to determine the newborn’s need for
resuscitation at birth. All newborns are rescored at 5 minutes. The newborn does not have a
low score.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
5. The nurse is assessing a 3-day-old, breastfed newborn who weighed 7 pounds, 8 ounces at
birth. The newborn’s mother is now concerned that the newborn weighs 6 pounds, 15 ounces.
Which is the most appropriate nursing intervention?
a. Recommend supplemental feedings of formula.
b. Explain that newborns may lose approximately 10% of birth weight within the first
week of life.
c. Assess child further to determine cause of excessive weight loss.
d. Encourage mother to express breast milk for bottle feeding the newborn.
ANS: B
The newborn normally loses about 10% of the birth weight by age 3 or 4 days. The birth
weight is usually regained by the tenth day of life. Because this is an expected occurrence, no
further action is needed. The mother should be taught about normal newborn feeding and
growing patterns.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. The nurse would expect the apical heart rate of a stabilized newborn to be in which range?
a. 60 to 80 beats/min
b. 80 to 100 beats/min
c. 120 to 140 beats/min
d. 160 to 180 beats/min
ANS: C
The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is
between 120 and 140 beats/min; 60 to 100 beats/min is too slow for a neonate and 160 to 180
beats/min is too fast for a neonate.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. A nurse is palpating a newborn’s fontanels. The nurse documents the anterior fontanel is
which shape?
Circle
Triangle
Square
Diamond
a.
b.
c.
d.
ANS: D
The anterior fontanel is diamond-shaped and measures from barely palpable to 4 to 5 cm.
Neither of the fontanels is a circle or a square. The triangle is the shape of the posterior
fontanel.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
8. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large,
edematous, and pendulous. This would be interpreted as a(n)
normal finding.
hydrocele.
absence of testes.
inguinal hernia.
a.
b.
c.
d.
ANS: A
A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a
breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral,
which usually resolves within a few months. The presence or absence of testes would be
determined on palpation of the scrotum and inguinal canal. Absence of testes may be an
indication of ambiguous genitalia. An inguinal hernia may be present at birth. It is more easily
detected when the child is crying.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head
toward that side and begin to suck. This is which reflex?
Perez
Sucking
Rooting
Extrusion
a.
b.
c.
d.
ANS: C
Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head
toward that side and begin to suck is a description of the rooting reflex, which usually
disappears by ages 3 to 4 months but may persist for up to 12 months. The Perez reflex
involves stroking the newborn’s back when prone; the child flexes extremities, elevating head
and pelvis. It disappears at ages 4 to 6 months. The newborn begins strong sucking
movements in response to circumoral stimulation. The reflex persists throughout infancy, even
without stimulation. Newborns force their tongues outward, when the tongue is touched or
depressed. This reflex usually disappears by age 4 months.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. At the time of birth, which is the grayish white, cheeselike substance that normally covers the
newborn’s skin called?
a. Miliaria
b. Meconium
c. Amniotic fluid
d. Vernix caseosa
ANS: D
The grayish white, cheeselike substance that normally covers the newborn’s skin is the vernix
caseosa. Miliaria are distended sweat glands that appear as minute vesicles. Meconium is the
newborn’s first stool. Amniotic fluid is produced in utero.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Where would acrocyanosis normally be present in the newborn shortly after birth?
a. Feet and hands
b. Bridge of nose
c. Circumoral area
d. Mucous membranes
ANS: A
Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns.
Cyanosis present at the bridge of the nose, the circumoral area, and the mucous membranes is
a potential sign of distress or major abnormality.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. The nurse observes flaring of nares in a newborn This would be interpreted as
a. nasal occlusion.
b. sign of respiratory distress.
c. common response to sneezing.
d. snuffles of congenital syphilis.
ANS: B
Nasal flaring is an indication of respiratory distress. A nasal occlusion would prevent the child
from breathing through the nose. Because newborns are obligatory nose breathers, this would
require immediate referral. Sneezing and thin white mucus drainage are common in newborns
and are not related to nasal flaring. Snuffles are indicated by a thick, bloody, nasal discharge
without sneezing.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
13. Parents of a newborn ask the nurse why vitamin K is being administered and the nurse
responds by explaining phytonadione (vitamin K) is administered to
a. prevent bleeding.
b. enhance immune response.
c. prevent bacterial infection.
d. maintain nutritional status.
ANS: A
Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is
synthesized by the intestinal flora. Because the newborn’s intestine is sterile and breast milk is
low in vitamin K, a supplemental source must be supplied. The purpose is not to enhance the
immune response, prevent bacterial infection, or maintain nutritional status. The major
function of vitamin K is to catalyze the liver synthesis of prothrombin, which is needed for
blood clotting and coagulation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
14. Recommendations for hepatitis B (HBV) vaccine of the full-term newborn include which
statement?
First dose is given between birth and age 2 days.
First dose is given between ages 12 and 15 months.
It is not recommended for neonates who are at low risk for hepatitis B.
It is not recommended for neonates whose mothers are positive for HBV surface
antigen.
a.
b.
c.
d.
ANS: A
To reduce the incidence of HBV in children and its serious consequences in adulthood, the
first of three doses is recommended soon after birth and before hospital discharge. Between 12
and 15 months is too late. The recommendation is for the first dose to be given soon after
birth. It is recommended for all newborns. Newborns born to mothers who are HBV surface
antigen positive should be given the vaccine within 12 hours of birth. They also should be
given hepatitis B immune globulin.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
15. The parents ask how their newborn should be bathed the first week home. How would the
nurse recommend to bathe the newborn?
Daily with mild soap
Daily with an alkaline soap
Two or three times this week with plain water
Two or three times this week with mild soap
a.
b.
c.
d.
ANS: C
The newborn newborn’s skin has a pH of approximately 5. This acidic pH has a bacteriostatic
effect. The parents should be taught to use only plain warm water for the bath and to bathe the
child no more than two or three times a week for the first 2 weeks. Soaps are alkaline. They
will alter the acid mantle of the child’s skin, providing a medium for bacterial growth.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. 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.)
Covering the cord with the diaper
Cleansing the cord with water daily
Keeping the cord area free of urine and stool
Monitoring for signs of infection
Applying bacitracin ointment to the cord daily
a.
b.
c.
d.
e.
ANS: B, C, D
Parents are taught to keep the cord area free of urine and stool, cleanse daily with water if
needed, and observe for any signs of infection. The diaper should not cover the cord. The
diaper is folded in front below the cord to avoid irritation and wetness on the site. Bacitracin
ointment should not be applied because the cord area should be kept dry, not moist.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed.
Which would the nurse include in the teaching session? (Select all that apply.)
Limiting the feeding to 15 minutes
Propping the bottle for night feedings is acceptable
Proper technique for cleansing the bottles and nipples
Feeding infant on alternate sides of the lap
Use of bottled water without fluoride should be avoided to mix powdered formula
a.
b.
c.
d.
e.
ANS: C, D
Parents preparing infant formula must wash their hands well and then wash all of the
equipment used to prepare the formula (including the cans of formula) with soap and water.
Sterilizing bottles and nipples 5 minutes in boiling water may be required when a hot-water
dishwasher is not available. Similar to breastfed infants, bottle-fed infants need to be held on
alternate sides of the lap to expose them to different stimuli. Bottled water should not be
considered sterile unless otherwise indicated; bottled water without fluoride should be avoided
for mixing infant formula. Propping the bottle during infant feedings at nighttime could cause
the infant to aspirate. The feeding should not be hurried. Even though they may suck
vigorously for the first 5 minutes and seem to be satisfied, infants should be allowed to
continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per
day, then about 20 minutes of sucking at each feeding provide for oral gratification.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is performing a gestational age assessment on a newborn. The nurse determines that
the newborn is “term” if which findings are assessed? (Select all that apply.)
Posture with fully flexed arms and legs
Arm recoil brisk
Square window at 90 degrees
Scarf sign of elbow crossing over the midline
Popliteal angle at 90 degrees
a.
b.
c.
d.
e.
ANS: A, B, E
A term newborn will have a posture that is fully flexed (arms and legs) and a brisk arm recoil.
The popliteal angle in a term infant is less than 90 degrees. The square window should show
no angle, the hand should lie flat on the ventral surface of the arm in the term newborn. In a
term newborn, the elbow should not cross the midline during assessment of the scarf sign.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
COMPLETION
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 which number as the Apgar? ______
(Record your answer in a whole number.)
ANS:
8
Sign
Heart rate
0
Absent
Respiratory
effort
Muscle tone
Absent
Reflex
irritability
Color
Limp
1
Slow, <100
beats/min
Irregular, slow,
weak cry
Some flexion of
extremities
Grimace
2
>100
beats/min
Good, strong
cry
Well flexed
No
Cry, sneeze
response
Blue, pale Body pink,
Completely
extremities blue pink
The newborn gets 2 for heart rate, 2 for respiratory effort, 1 for muscle tone, 2 for reflex
irritability and 1 for color = 8.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
2. A nurse is preparing to administer a prescribed phytonadione (vitamin K) injection 0.5 mg
intramuscularly to a newborn. The phytonadione (vitamin K) ampule is labeled 1 mg equals
0.5 ml. How many milliliters will the nurse administer? ______ (Record your answer using
two decimal places.)
ANS:
0.25
Formula: Desired/Available  Volume = 0.5 mg/1 mg  0.5 mL = 0.25 mL.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 08: Health Problems of Newborns
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which finding on a newborn assessment would the nurse recognize as suggestive of a clavicle
fracture?
Negative scarf sign
Asymmetric Moro reflex
Swelling of fingers on affected side
Paralysis of affected extremity and muscles
a.
b.
c.
d.
ANS: B
A newborn with a broken clavicle may have no symptoms. The Moro reflex, which results in
sudden extension and abduction of the extremities followed by flexion and adduction of the
extremities, will most likely be asymmetric. The scarf sign that is used to determine
gestational age should not be performed if a broken clavicle is suspected. Swelling of fingers
on affected side and paralysis of affected extremity and muscles are not indicative of a
fractured clavicle.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will
be. Which information does the nurse need to include in the response?
a. Excision of the lesion will be necessary.
b. Injections of prednisone into the lesion will reduce it.
c. No treatment is usually necessary because of the high rate of spontaneous
involution.
d. Pulsed dye laser treatments will be necessary immediately to prevent permanent
disability.
ANS: C
There is a high rate of spontaneous resolution, so treatment is usually not indicated for
hemangiomas. Surgical removal would not be indicated. If steroids are indicated, then
systemic prednisone is administered for 2 to 3 weeks. The pulse dye laser is used in the
uncommon situation of potential visual or respiratory impairment.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is caring for a very low birth weight (VLBW) newborn with a peripheral
intravenous infusion. Which statement describes nursing considerations regarding infiltration?
Infiltration occurs frequently because The catheter is not secured to the skin.
Continuous infusion pumps stop automatically when infiltration occurs.
Parenteral fluids can cause severe tissue damage if infiltration occurs.
Infusion site should be checked for infiltration at least once per 8-hour shift.
a.
b.
c.
d.
ANS: C
Hypertonic fluids can damage cells if the fluid leaks from the vein. Careful monitoring is
required to prevent severe tissue damage. Infiltrations occur for many reasons, not only
activity. The vein, catheter, and fluid used all contribute to the possibility of infiltration. The
continuous infusion pump may alarm when the pressure increases, but this does not alert the
nurse to all infiltrations. Infusion rates and sites should be checked hourly to prevent tissue
damage from extravasations, fluid overload, and dehydration.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
4. The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer and
notes blanching of the feet. Which is the most appropriate nursing action?
Elevate feet 15 degrees.
Place socks on newborn.
Wrap feet loosely in prewarmed blanket.
Report findings immediately to the practitioner.
a.
b.
c.
d.
ANS: D
Blanching of the feet, in a newborn with an umbilical catheter, is an indication of vasospasm.
Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair
circulation. It is an emergency situation and must be reported immediately.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
5. Which is the most appropriate nursing action when intermittently gavage-feeding a preterm
newborn?
Allow formula to flow by gravity.
Insert a 14 french tube.
Avoid letting newborn suck on tube.
Apply steady pressure to syringe to deliver formula to stomach in a timely manner.
a.
b.
c.
d.
ANS: A
The formula is allowed to flow by gravity. The length of time to complete the feeding will
vary. Preferably, the tube is inserted through the mouth. Newborns are obligatory nose
breathers, and the presence of the tube in the nose irritates the nasal mucosa. Passage of the
tube through the mouth allows the nurse to observe and evaluate the sucking response. The
feeding should not be done under pressure. This procedure is not used as a timesaver for the
nurse.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
6. Which is an important nursing action related to the use of tape and/or adhesives on preterm
newborns?
Avoid using tape and adhesives until skin is more mature.
Use solvents to remove tape and adhesives instead of pulling on skin.
Remove adhesives with warm water or mineral oil.
Use scissors carefully to remove tape instead of pulling tape off.
a.
b.
c.
d.
ANS: C
Warm water, mineral oil, or petrolatum can be used to facilitate the removal of adhesive. In
the preterm newborn, often it is impossible to avoid using adhesives and tape. The smallest
amount of adhesive necessary should be used. Solvents should be avoided because they tend
to dry and burn the delicate skin. Scissors should not be used to remove dressings or tape from
the extremities of very small and immature newborns because it is easy to snip off tiny
extremities or nick loosely attached skin.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
7. The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While
taking vital signs and changing the newborn’s diaper, the nurse observes the newborn’s color
is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and
heart rate is regular and rapid. The nurse would recognize these behaviors as manifestations of
a. stress.
b. subtle seizures.
c. preterm behavior.
d. onset of respiratory distress.
ANS: A
Color pink but slightly mottled, arms and legs limp and extended, hiccups, respiratory pauses
and gasping, and an irregular, rapid heart rate are signs of stress or fatigue in a newborn.
Neonatal seizures usually have some type of repetitive movement from twitching to rhythmic
jerking movements. The behavior of a preterm newborn may be inactive and listless.
Respiratory distress is exhibited by retractions and nasal flaring.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
8. The nurse is planning care for a family expecting their newborn to die. Knowing this is an
important step in the grieving process, the nurse’s interventions would 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
9. When would the nurse expect breastfeeding-associated jaundice to first appear in a normal
newborn?
0 to 12 hours
12 to 24 hours
2 to 4 days
4 to 5 days
a.
b.
c.
d.
ANS: C
Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased
caloric and fluid intake by the newborn before the mother’s milk is well established. Fasting is
associated with decreased hepatic clearance of bilirubin; 0 to 24 hours is too soon. Jaundice
within the first 24 hours is associated with hemolytic disease of the newborn; 4 to 5 days is
too late. Jaundice at this time may be due to breast milk jaundice.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
10. The newborn with severe jaundice is at risk for developing
a. encephalopathy.
b. bullous impetigo.
c. respiratory distress.
d. blood incompatibility.
ANS: A
Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. A
newborn with severe jaundice is at risk for developing kernicterus or bilirubin
encephalopathy. Encephalopathy is a highly infectious bacterial infection of the skin. It has no
relation to severe jaundice and is the most likely complication of severe jaundice. A blood
incompatibility may be the causative factor for the severe jaundice.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
11. Hemolytic disease is suspected in a mother’s second newborn. Which factor is important in
understanding how this could develop?
The mother’s first child was Rh positive.
The mother is Rh positive.
Both parents have type O blood.
RhIG (RhoGAM) was given to the mother during her first pregnancy.
a.
b.
c.
d.
ANS: A
Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell
(RBC) destruction. The major causes of this are Rh and maternal-fetal ABO incompatibility. If
an Rh-negative mother has previously been exposed to Rh-positive blood through pregnancy
or blood transfusion, antibodies to this blood group antigen may develop so that she is
isoimmunized. With further exposure to Rh, the maternal antibodies will agglutinate with the
red cells of the fetus who has the antigen and destroy the cells. Hemolytic disease is also
caused by ABO incompatibilities. Blood type is the important consideration. If both parents
are type O blood, ABO incompatibility would not be a possibility. The mother should have
received Rho(D) immune globulin to prevent antibody development after the first pregnancy.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
12. Which is the primary treatment for hypoglycemia in newborns with feeding intolerance?
a. Oral glucose feedings
b. Intravenous (IV) infusion of glucose
c. Short-term insulin therapy
d. Feedings (formula or breast milk) at least every 2 hours
ANS: B
IV infusions of glucose are indicated when the glucose level is very low and when feedings
are not tolerated. Early feedings in the normoglycemic newborn are preventive. When the
newborn is unable to tolerate feedings or the blood glucose level has become extremely low,
then IV infusions are indicated. Insulin administration will further depress the blood glucose
level. Feedings can be preventive. The child may not be able to tolerate this frequency.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
13. Which is the most appropriate nursing intervention for the newborn who is jittery and
twitching and has a high-pitched cry?
Monitor blood pressure closely.
Obtain urine sample to detect glycosuria.
Obtain serum glucose and serum calcium levels.
Administer oral glucose or, if newborn refuses to suck, IV dextrose.
a.
b.
c.
d.
ANS: C
These are signs and symptoms of hypocalcemia and hypoglycemia. A blood test is useful to
determine the treatment. Laboratory analysis for calcium and blood glucose should be the
priority intervention. Monitoring vital signs is important, but recognition of the possible
hypocalcemia and hypoglycemia is imperative. A finding of glycosuria would not facilitate the
diagnosis of hypoglycemia. A determination must be made between the hypocalcemia and
hypoglycemia before treatment can be initiated.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
14. The nurse is caring for a preterm newborn who requires mechanical ventilation for the
treatment of respiratory distress syndrome. Which is the preterm newborn at risk for due to the
mechanical ventilation?
a. Alveolar damage
b. Meconium aspiration
c. Transient tachypnea
d. Retractions and nasal flaring
ANS: A
Positive pressure introduced by mechanical apparatus has created an increase in the incidence
of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia.
Meconium aspiration is not associated with mechanical ventilation. Tachypnea may be an
indication of a pneumothorax, but it would not be transient. Retractions and nasal flaring are
indications of the use of accessory muscles when the newborn cannot obtain sufficient
oxygen. The use of mechanical ventilation bypasses the newborn’s need to use these muscles.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
15. The nurse is caring for a newborn whose mother is diabetic. Which clinical manifestations
would the nurse expect to see?
Hypoglycemic, large for gestational age
Hyperglycemic, large for gestational age
Hypoglycemic, small for gestational age
Hyperglycemic, small for gestational age
a.
b.
c.
d.
ANS: A
The clinical manifestations of a newborn born to a mother with diabetes include being large
for gestational age, being plump and full-faced, having abundant vernix caseosa, being listless
and lethargic, and having hypoglycemia. These manifestations appear a short time after birth.
The newborn is hypoglycemic from increased fetal production of insulin and large for
gestational age.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
16. 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 would the nurse suspect?
a. Seizure disorder
b. Narcotic withdrawal
c. Placental insufficiency
d. Meconium aspiration syndrome
ANS: B
Newborns exposed to drugs in utero usually show no untoward effects until 12 to 24 hours for
heroin or much longer for methadone. The newborn usually has nonspecific signs that may
coexist with other conditions such as hypocalcemia and hypoglycemia. In addition, these
newborns may have loose stools, tachycardia, fever, projectile vomiting, sneezing, and
generalized sweating, which is uncommon in newborns. Loose stools, tachycardia, fever,
projectile vomiting, sneezing, and generalized sweating are manifestations not descriptive of
seizure activity. Placental insufficiency usually results in a child who is small for gestational
age. Meconium aspiration syndrome usually has manifestations of respiratory distress.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
17. Which is an important nursing consideration in preventing the complications of congenital
hypothyroidism (CH)?
a.
b.
c.
d.
Assess for family history of CH.
Assess mother for signs of hypothyroidism.
Be certain appropriate screening is done prenatally.
Be certain appropriate screening is done on newborn.
ANS: D
Because CH is one of the most common preventable causes of cognitive impairment, early
diagnosis and treatment is essential. Neonatal screening (not prenatal) consists of an initial
filter paper blood spot T4 measurement. The majority of cases are nonhereditary although
15% of all cases are transmitted as an autosomal dominant trait. An assessment of previous
maternal hyperthyroidism is appropriate, not hypothyroidism.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Phenylketonuria (PKU) is a genetic disease that results in the body’s inability to correctly
metabolize
glucose.
phenylalanine.
phenylketones.
thyroxine.
a.
b.
c.
d.
ANS: B
Early diagnosis and treatment are essential to prevent the complications of CH. Neonatal
screening is mandatory in all 50 United States and territories and is usually obtained in the
first 24 to 48 hours of birth. A number of different etiologies exist for CH; family history will
identify a small percentage only. The screening can be done postnatally on blood obtained via
heel stick.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
19. Which disorder is the Guthrie blood test used to assist in diagnosis?
a. Down syndrome
b. Isoimmunization
c. PKU
d. Congenital hypothyroidism (CH)
ANS: C
The Guthrie blood test is an assay commonly used to diagnosis PKU. The test should be
performed after the newborn has received postnatal feedings. Down syndrome is diagnosed
through chromosomal analysis. Isoimmunization is detected by analysis of blood for
unexpected antibodies. CH is diagnosed by analysis of a filter paper blood spot for thyroxine
(T4).
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse needs to obtain blood for ongoing assessment of a high-risk newborn’s progress.
Which tests would the nurse monitor? (Select all that apply.)
Blood glucose
Complete blood count (CBC)
Calcium
Serum electrolytes
Neonatal prothrombin time (PTT)
a.
b.
c.
d.
e.
ANS: A, C, D
The most common blood tests done on high-risk newborns are blood glucose, bilirubin,
calcium, hematocrit, serum electrolytes, and blood gases. Hematocrits rather than CBCs are
performed. This will monitor the red cell volume. Neonatal prothrombin time (PTT) is not a
test.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
2. Which are clinical manifestations of the postterm newborn? (Select all that apply.)
a. Excessive lanugo
b. Increased subcutaneous fat
c. Abundance of scalp hair
d. Parchment-like skin
e. Minimal vernix caseosa
f. Long fingernails
ANS: C, D, E, F
In postterm newborns, the skin is often cracked, parchment-like, and desquamating; there is
little to no vernix caseosa; and fingernails are long. Lanugo is usually absent in postterm
newborns. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance.
Scalp hair is usually abundant.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are
appropriate? (Select all that apply.)
a. Avoid stimulation.
b. Decrease fluid intake.
c. Expose all the newborn’s skin.
d. Monitor skin temperature closely.
e. Reposition the newborn every 2 hours.
f. Cover the newborn’s eyes with eye shields or patches.
ANS: C, D, E, F
Several nursing interventions are instituted to protect the newborn during phototherapy.
Temperature is closely monitored to prevent hyperthermia or hypothermia. The newborn is
repositioned every 2 hours to maximize exposure to the phototherapy and to prevent skin
breakdown. The infant’s eyes are shielded by an opaque mask to prevent exposure to the light.
The newborn is clothed in a diaper because a side effect of phototherapy includes loose,
greenish stools. Other side effects include increased metabolic rate; dehydration; electrolyte
disturbances, such as hypocalcemia; and priapism. Infants receiving phototherapy may require
additional fluid volume to compensate for insensible and intestinal fluid loss. The infant
should receive adequate stimulation, which includes feeding and touching.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment
4. A nurse is assessing a preterm newborn for the possibility of necrotizing enterocolitis (NEC).
Which assessment findings would the nurse expect to find if NEC is confirmed? (Select all
that apply.)
a. Minimal gastric residual
b. Abdominal distention
c. Apneic episodes
d. Urinary output at 2 ml/kg/hr
e. Unstable temperature
ANS: B, C, D
The nurse should observe for indications of early development of NEC by checking the
appearance of the abdomen for distention (measuring abdominal girth, measuring residual
gastric contents before feedings, and listening for bowel sounds) and performing all routine
assessments for high-risk neonates. The preterm newborn may have apnea and unstable
temperature if NEC is developing. The urinary output will be decreased and will be below the
expected 2 ml/kg/hr.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
5. A nurse is admitting a preterm newborn to the NICU. Which interventions would the nurse
implement to prevent retinopathy? (Select all that apply.)
Place on pulse oximetry.
Decrease exposure to bright, direct lighting.
Place on a cardiac monitor.
Cover eyes with an eye shield at night.
Use supplemental oxygen only when needed.
a.
b.
c.
d.
e.
ANS: A, B, D
To prevent retinopathy, the nurse should provide preventive care by closely monitoring blood
oxygen levels, responding promptly to saturation alarms, and preventing fluctuations in blood
oxygen levels. Pulse oximetry is recommended to monitor the infant’s oxygenation status
during resuscitation and to prevent excessive use of oxygen in both term and preterm infants.
Decrease exposure to bright, direct lighting; although exposure to bright light has not been
proven to contribute to retinopathy of prematurity, such exposure is undesirable from a
neurobehavioral developmental perspective. Use supplemental oxygen judiciously and
monitor oxygen blood levels carefully; prevent wide fluctuations in oxygen blood levels
(hyperoxia and hypoxia). Placing the newborn on a cardiac monitor will not prevent
retinopathy. Covering the eyes with eye shields is not a preventive measure for retinopathy.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
6. A nurse is reviewing acid-base laboratory data on a newborn admitted to the NICU for
meconium aspiration. Which laboratory values would the nurse report to the physician?
(Select all that apply.)
a. pH: 7.35
b. PCO2: 49
c. HCO3–: 25
d. Base excess: –5
e. Anion gap: 11
ANS: A, B
Normal values of pH for a newborn are:
Birth: 7.11–7.36
1 day: 7.29–7.45
Child: 7.35–7.45.
Normal values of PCO2 are:
Newborn: 27–40 mm Hg
Infant: 27–41 mm Hg
Girls: 32–45 mm Hg
Boys: 35–48 mm Hg.
Normal values for HCO33– are:
Infant: 21–28 mEq/ml
Thereafter: 22–26 mEq/ml.
The PaO2 is within normal limits for a newborn. Therefore, the nurse should report the PCO2
of 49 and the HCO3– of 30.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 09: Health Promotion of the Infant and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A nurse is assessing a 12-month-old infant. Which statement best describes the infant’s
physical development a nurse would expect to find?
Anterior fontanel closes by age 6 to 10 months.
Binocularity is well established by age 8 months.
Birth weight triples by age 1 year.
Maternal iron stores persist during the first 12 months of life.
a.
b.
c.
d.
ANS: C
Growth is very rapid during the first year of life. The birth weight has approximately doubled
by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18
months. Binocularity is not established until age 15 months. Maternal iron stores are usually
depleted by age 6 months.
DIF: Cognitive Level: Understand
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
would expect the infant to now weigh approximately how many pounds?
10
15
20
25
a.
b.
c.
d.
ANS: B
Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds
at birth would weigh approximately 15 pounds; 10 pounds is too little. The infant would have
gone from the 50th percentile at birth to below the 5th percentile; 20 to 25 pounds is too
much. The infant would have tripled the birth weight at 6 months.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior
fontanel is closed. How would the nurse interpret this finding?
Normal finding
Finding requiring a referral
Abnormal finding
Normal finding, but requires rechecking in 1 month
a.
b.
c.
d.
ANS: A
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No
further intervention is required.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas
and corn are not completely digested and can be seen in their infant’s stools. The nurse’s
explanation of this is based on which statement?
a. Child should not be given fibrous foods until digestive tract matures at age 4 years.
b. Child should not be given any solid foods 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. At which age can most infants sit steadily unsupported?
a. 4 months
b. 6 months
c. 8 months
d. 10 months
ANS: C
Sitting erect without support is a developmental milestone usually achieved by 8 months. At
age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting
position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often
prone (face down) while awake. Which knowledge would the nurse’s response should be
based?
a. Unacceptable because of the risk of sudden infant death syndrome (SIDS)
b. Unacceptable because it does not encourage achievement of developmental
milestones
c. Acceptable to encourage fine motor 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.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
7. By which age would the nurse expect an infant to be able to sit down from a standing
position?
6 months
8 months
12 months
15 months
a.
b.
c.
d.
ANS: C
A 12-month-old infant should be able to sit down from a standing position without assistance.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. 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?
Recognizes familiar face, such as mother
Recognizes familiar object, such as bottle
Actively searches for a hidden object
Secures objects by pulling on a string
a.
b.
c.
d.
ANS: C
During the first 6 months of life, infants believe that objects exist only as long as they can see
them. When infants search for an object that is out of sight, this signals the attainment of
object permanence, whereby an infant knows an object exists even when it is not visible.
Between ages 8 and 12 weeks, infants begin to respond differentially to the mother. They cry,
smile, vocalize, and show distinct preference for the mother. This preference is one of the
stages that influences the attachment process but is too early for object permanence.
Recognizing familiar objects is an important transition for the infant, but it does not signal
object permanence. The ability to understand cause and effect is part of secondary schemata
development.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
9. Which is an appropriate play activity for a 7-month-old infant to encourage visual
stimulation?
a. Playing peek-a-boo
b. Playing pat-a-cake
c. Imitating animal sounds
d. Showing how to clap hands
ANS: A
Because object permanence is a new achievement, peek-a-boo is an excellent activity to
practice this new skill for visual stimulation. Pat-a-cake and showing how to clap hands will
help with kinetic stimulation. Imitating animal sounds will help with auditory stimulation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
10. At which age does an infant start to recognize familiar faces and objects, such as a feeding
bottle?
a. 1 month
b. 2 months
c. 3 months
d. 4 months
ANS: C
The child can recognize familiar objects at approximately age 3 months. For the first 2 months
of life, infants watch and observe their surroundings. The 4-month-old infant is able to
anticipate feeding after seeing the bottle.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. A parent asks the nurse “when will my infant start to teethe?” The nurse responds that the
earliest age at which an infant begins teething with eruption of lower central incisors is _____
months.
a. 4
b. 6
c. 8
d. 12
ANS: B
Teething usually begins at age 6 months with the eruption of the lower central incisors; 4
months is too early for teething. By age 8 months, the infant has the upper and lower central
incisors. At age 12 months, the infant has six to eight deciduous teeth.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
12. The nurse would teach parents that which age is safe to give infants whole milk instead of
commercial infant formula?
6 months
9 months
12 months
18 months
a.
b.
c.
d.
ANS: C
The American Academy of Pediatrics does not recommend the use of cow’s milk for children
younger than 12 months. At 6 and 9 months, the infant should be receiving commercial infant
formula or breast milk. At age 18 months, milk and formula are supplemented with solid
foods, water, and some fruit juices.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. The parents of a 4-month-old infant tell the nurse that they are heating the baby’s formula in a
microwave oven. Which would the nurse recommend?
Never heat a bottle in a microwave oven.
Heat only 10 ounces or more.
Always leave bottle top uncovered to allow heat to escape.
Shake bottle vigorously for at least 30 seconds after heating.
a.
b.
c.
d.
ANS: A
Bottles cannot be heated safely in microwave ovens even if safe guidelines are followed and
regardless of the amount to be heated due to uneven heating and possible burns.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. Parents tell the nurse that their 6-month-old son often sleeps with them. They seem
unconcerned about this. The nurse’s response would be based on which statement?
a. Separation from parents should be completed by this age.
b. Daytime attention should be increased.
c. This is a common and accepted practice, especially in some cultural groups.
d. Infants should not sleep in an adult bed due to the risk of suffocation.
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride
supplements are needed. Which is the nurse’s best response?
“She needs to begin taking them now.”
“They are not needed if you drink fluoridated water.”
“She may need to begin taking them at age 6 months.”
“She can have infant cereal mixed with fluoridated water instead of supplements.”
a.
b.
c.
d.
ANS: C
Fluoride supplementation is recommended by the American Academy of Pediatrics beginning
at age 6 months if the child is not drinking adequate amounts of fluoridated water (0.3 ppm).
The amount of water that is ingested and the amount of fluoride in the water are taken into
account when supplementation is being considered.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. The clinic is lending a federally approved car seat to an infant’s family. The nurse would
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 air bag 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 infant’s disproportionately heavy
head and weak neck. The middle of the back seat is the safest position for the child. The infant
must be rear facing to protect the head and neck in the event of an accident. Severe injuries
and deaths in children have occurred from air bags deploying on impact in the front passenger
seat.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. In terms of gross motor development, which would the nurse expect a 5-month-old infant to
do? (Select all that apply.)
Roll from abdomen to back.
Put feet in mouth when supine.
Roll from back to abdomen.
Sit erect without support.
Move from prone to sitting position.
Adjust posture to reach an object.
a.
b.
c.
d.
e.
f.
ANS: A, B
Rolling from abdomen and to back and placing the feet in the mouth when supine are
developmentally appropriate for a 5-month-old infant. The ability to roll from back to
abdomen usually occurs at 6 months old. Sitting erect without support is a developmental
milestone usually achieved by 8 months. The 10-month-old infant can usually move from a
prone to a sitting position. The 8-month-old infant adjusts posture to reach an object.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A nurse is teaching a parent about administration of iron supplements to a 7-month-old infant.
Which would the nurse include in the teaching session? (Select all that apply.)
a. Administer the iron supplement with a dropper toward the side and to the back of
b.
c.
d.
e.
the mouth.
Administer the iron supplement with feedings.
Your infant’s stools may look tarry green.
Your infant may have some diarrhea initially.
Follow the iron supplement with 4 ounces of juice.
ANS: A, C
Liquid iron supplements may stain the teeth; therefore, administer them with a dropper toward
the back of the mouth (side). Ideally, iron supplements should be administered between meals
for greater absorption. Avoid administration of liquid iron supplements with whole cow’s milk
or milk products because they bind free iron and prevent absorption. Educate parents that iron
supplements will turn stools black or tarry green. Iron supplements may cause transient
constipation, not diarrhea. In older children, follow liquid iron supplement with a citrus fruit
or juice drink (no more than 3 to 4 oz).
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A nurse is teaching a parent about introduction of solid foods into an infant’s diet. Which
would the nurse include in the teaching session? (Select all that apply.)
Solid food introduction can be started at 4 to 6 months of age.
Iron fortified cereal is introduced first.
Begin the introduction of solid foods by mixing with formula in the bottle.
Introduce egg white in small quantities (1 tsp) at 6 months.
Introduce one food at a time, usually at intervals of 4 to 7 days.
a.
b.
c.
d.
e.
ANS: A, B, E
Rice cereal, because of its low allergenic potential, is the first solid food introduced to an
infant at 4 to 6 months of age. Introduce one food at a time, usually at intervals of 4 to 7 days,
to identify food allergies. Introduce egg white in small quantities (1 tsp) toward the end of the
first year to detect an allergy. Solid food introduction should be started at 4 to 6 months of
age. Never introduce foods by mixing them with the formula in a bottle.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the expected sequence of fine motor developmental milestones for an infant
beginning with the first milestone achieved and ending with the last milestone achieved.
Provide answer using lowercase letters separated by commas (e.g., A, B, C, D, E).
a. Hands kept loosely open
b. Strong grasp reflex
c. Transfers object between hands
d. Plays with toes
e. Masters crude pincer grasp
ANS:
B, A, D, C, E
Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary.
By 5 months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using
the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10
months of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a
neat pincer grasp. By 11 months, they put objects into containers and like to remove them. By
age 1 year, infants try to build towers of two blocks but fail.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 10: Health Problems of Infants
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which vitamin is recommended for all women of childbearing age to reduce the risk of neural
tube defects?
A
C
Niacin
Folic acid
a.
b.
c.
d.
ANS: D
The vitamin supplement that is recommended for all women of childbearing age is a daily
dose of 0.4 mg of folic acid. Folic acid taken before conception and during pregnancy can
reduce the risk of neural tube defects by 70%. No correlation exists between vitamins A, C, or
folic acid and neural tube defects.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. Which findings would the nurse expect when assessing a child with kwashiorkor disease?
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 are common findings in malnourished
children with kwashiorkor.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
3. Marasmus is seen in children 6 months to 2 years in underdeveloped countries. Which
symptoms would the nurse expect for this condition?
Loose, wrinkled skin
Edematous skin
Depigmentation of the skin
Dermatoses
a.
b.
c.
d.
ANS: A
Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of
subcutaneous fat. The child appears to be very old, with loose and wrinkled skin, unlike the
child with kwashiorkor, who appears more rounded from the edema. Fat metabolism is less
impaired than in kwashiorkor; thus, deficiency of fat-soluble vitamins is usually minimal or
absent. In general, the clinical manifestations of marasmus are similar to those seen in
kwashiorkor with the following exceptions: With marasmus, there is no edema from
hypoalbuminemia or sodium retention, which contributes to a severely emaciated appearance;
no dermatoses caused by vitamin deficiencies; little or no depigmentation of hair or skin;
moderately normal fat metabolism and lipid absorption; and a smaller head size and slower
recovery after treatment.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. Rickets is caused by a deficiency in
a. vitamin A.
b. vitamin C.
c. vitamin D.
d. folic acid.
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
5. The nurse counsels the parents of an infant 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
6. Children on vegan diets are at risk for a deficiency of which substance?
a. Fat
b. Protein
c. Vitamin C
d. Vitamin B12
ANS: D
Children on vegetarian diets, especially vegan diets are at risk for vitamin B12 deficiency, so
it must be ensured that an adequate source of this vitamin is consumed through either
supplements or fortified foods. Fats, proteins and vitamin C can be obtained from a variety of
fruits, vegetables, legumes, and nuts.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which would the nurse recommend as a substitute formula for an infant with a cow’s milk
allergy?
Nutramigen
Goat’s milk
Similac
Enfamil
a.
b.
c.
d.
ANS: A
Treatment of CMA is elimination of cow’s milk–based formula and all other dairy products.
For infants fed cow’s milk formula, this primarily involves changing the formula to a casein
hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum). Goat’s milk (raw) is not
an acceptable substitute because it cross-reacts with cow’s milk protein, is deficient in folic
acid, has a high sodium and protein content, and is unsuitable as the only source of calories.
Cow’s milk protein is contained in both Enfamil and Similac.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
8. Which action is taken by the nurse when a parent of an infant with colic verbalizes, “All this
baby does is scream at me; it is a constant worry.”
a. Provide methods for coping to the mother.
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 parent’s anxieties. The nurse should reassure the parent that he or she is
not doing anything wrong. Colic is multifactorial. The infant with colic is experiencing
spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day.
Telling the parent that it will eventually go away does not help him or her through the current
situation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
9. Which is an important nursing responsibility when dealing with a family experiencing the loss
of an infant from sudden infant death syndrome (SIDS)?
a. Explain how SIDS could have been predicted and prevented.
b. Interview parents in depth concerning the circumstances surrounding the child’s
death.
c. Discourage parents from making a last visit with the infant.
d. Ensure arrangements are made for a follow-up home visit to parents as soon as
possible after the child’s 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
10. 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 infant’s trunk should be gently stimulated by patting or rubbing. If
the infant is prone, turn onto the back. The infant should not be shaken vigorously, the head
rolled side to side, or held by the feet upside down with the head supported. These can cause
injury.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
11. To prevent plagiocephaly, the nurse would 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
12. Which statement by a parent indicates an understanding of a home apnea monitor?
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 always look at the baby first if the alarm sounds.
d. “We will place the monitor in the crib with our infant.”
ANS: C
The parents should check the monitor several times a day to be sure the alarm is working and
that it can be heard from room to room. The parents should not adjust the monitor to eliminate
false alarms. Adjustments could compromise the monitor’s effectiveness. The monitor should
be placed on a firm surface away from the crib and drapes. The parents should not sleep in the
same bed as the monitored infant.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
13. Which would 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 parent’s bed, or give bottle or pacifier.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
14. Which intervention would the nurse implement when feeding a 12-month-old infant with
failure to thrive?
Provide stimulation during feeding.
Avoid being persistent during feeding time.
Limit feeding time to 10 minutes.
Assess difficulties encountered during feeding.
a.
b.
c.
d.
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
15. Which would the nurse include in the instructions for seborrhea dermatitis (cradle cap)?
a.
b.
c.
d.
Shampoo every three days with a mild soap.
The hair should be shampooed with a medicated shampoo.
Shampoo every day with a mild soap or antiseborrheic shampoo.
The loosened crusts should not be removed with a fine-toothed comb.
ANS: C
When seborrheic lesions are present, the treatment is directed at removing the crusts. Parents
are taught the appropriate procedure to clean the scalp. Shampooing should be done daily with
a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an
antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied
to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is
thoroughly rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts
from the strands of hair after shampooing.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. While conducting an educational class, which risk factors would the nurse include as
increasing an infant’s risk of a sudden infant death syndrome incident? (Select all that apply.)
Maternal smoking
Co-sleeping
Vaccinations
Prone sleeping
Recent viral illness
a.
b.
c.
d.
e.
ANS: A, B, D
Certain groups of infants are at increased risk for SIDS: low birth weight, low Apgar scores,
recent viral illness, and male sex. Breastfed infants and infants of average or above average
weight are not at higher risk for SIDS.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which are the clinical manifestations the nurse expects to assess in an infant with cow’s milk
allergy? (Select all that apply.)
Eczema
Vomiting
Rhinitis
Abdominal pain
Moist skin
a.
b.
c.
d.
e.
ANS: A, B, C
An infant with cow’s milk allergy will possibly have vomiting, rhinitis, and abdominal pain.
The mucous membranes may be pale due to anemia from blood lost in the GI tract, and the
skin will be itchy with the possibility of atopic dermatitis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
3. The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema) and would
suggest which of the following to the parent? (Select all that apply.)
“You can use warm wet compresses to relieve discomfort.”
“You will need to keep your infant’s fingernails and toenails cut short.”
“You should bathe your baby in a bubble bath two times a day.”
“You will need to prevent your baby from scratching the area by using a mild
antihistamine.”
e. “You can try a fabric softener in the laundry to avoid rough cloth.”
f. “You should apply an emollient to the skin immediately after a bath.”
a.
b.
c.
d.
ANS: A, B, F
The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new
lesions and secondary infection; an antihistamine can be used. Keeping the skin hydrated is a
goal of treating atopic dermatitis. Applying an emollient immediately after a bath helps to trap
moisture and prevent moisture loss. Cool wet compresses should be used for relief. Bubble
baths and harsh soaps should be avoided, as is bathing excessively, since this leads to drying.
Fabric softener should be avoided because of the irritant effects of some of its components.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
COMPLETION
1. The nurse is preparing to administer epinephrine 0.001 mg/kg. The child weighs 22 pounds.
What is the epinephrine dose the nurse would administer? ______ (Record your answer using
two decimal places.)
ANS:
0.01
Convert the 22 pounds to kilograms by dividing 22 by 2.2 = 10. Multiply the 10 by 0.001 mg
of epinephrine = 0.01 mg as the dose to be given.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
OTHER
1. A school nurse observes a child with nut allergies, (who just ingested some trail mix with
peanuts), in distress, wheezing and cyanotic. Place the interventions the nurse would
implement in order of the highest priority to the lowest priority. Provide answer using
lowercase letters separated by commas (e.g., A, B, C, D).
a. Call Jason’s parents and notify them of the situation.
b. Call Jason’s family practitioner to obtain further orders for medication.
c. Promptly administer an intramuscular dose of epinephrine.
d. Call 911 and wait for the emergency response personnel to arrive.
ANS:
C, D, B, A
The nurse would first administer epinephrine IM to a child with a food allergy who is in
obvious distress, wheezing, and cyanotic. 911 would be called after the epinephrine is
administered. The physician would be contacted for further orders and, last, the parents
notified of the situation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 11: Health Promotion of the Toddler and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which factor predisposes 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. Short, straight internal ear canal and large lymph tissue.
ANS: D
Toddlers continue to have the short, straight internal ear canal of infants. The lymphoid tissue
of the tonsils and adenoids continues to be relatively large. These two anatomic conditions
combine to predispose the toddler to frequent infections. The abdominal respirations and
lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection.
The defense mechanisms are more efficient compared with those of infancy.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. The psychosocial developmental tasks of toddlerhood include which characteristic?
a. Development of a conscience
b. Recognition of sex differences
c. Ability to get along with age-mates
d. Ability to delay gratification
ANS: D
If the need for basic trust has been satisfied, then toddlers can give up dependence for control,
independence, and autonomy. One of the tasks that the toddler is concerned with is the ability
to delay gratification. Development of a conscience occurs during the preschool years. The
recognition of sex differences occurs during the preschool years. The ability to get along with
age-mates develops during the preschool and school-age years.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A parent of an 18-month-old boy tells the nurse that he has rapid mood swings, and if he is
scolded, he shows anger and then immediately wants to be held. The nurse’s best
interpretation of this behavior is included in which statement?
a. This is normal behavior for his age.
b. This is unusual behavior for his age.
c. He is not effectively coping with stress.
d. He is showing he is not getting enough attention.
ANS: A
Toddlers use distinct behaviors in the quest for autonomy. They express their will with
continued negativity and the use of the word “no.” Children at this age also have rapid mood
swings. The nurse should reassure the parents that their child is engaged in expected behavior
for an 18-month-old. Having a rapid mood swing is an expected behavior for a toddler.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. A nurse is planning care for a 17-month-old child. According to Piaget, which stage would 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 Erikson’s first stage. Preoperational is the stage of cognitive development usually
present in older toddlers and preschoolers. Secondary circular reactions last from about ages 4
to 8 months.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which is descriptive of a toddler’s cognitive development at age 20 months?
a. Searches for an object only if he or she sees it being hidden
b. Realizes that “out of sight” is not out of reach
c. Puts objects into a container but cannot take them out
d. Understands the passage of time, such as “just a minute” and “in an hour”
ANS: B
At this age, the child is in the final sensorimotor stage. Children will now search for an object
in several potential places, even though they saw only the original hiding place. Children have
a more developed sense of objective permanence. They will search for objects even if they
have not seen them hidden. When a child puts objects into a container but cannot take them
out, this is indicative of tertiary circular reactions. An embryonic sense of time exists,
although the children may behave appropriately to time-oriented phrases; their sense of timing
is exaggerated.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A 16 months old child falls down a few stairs, then gets up and “scolds” the stairs as if they
caused him to fall. This is an example of which of the following?
a. Animism
b. Ritualism
c. Irreversibility
d. Delayed cognitive development
ANS: A
Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the
toddler is attributing human characteristics to them. Ritualism is the need to maintain the
sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the
inability to reverse or undo actions initiated physically. Steven is acting in an age-appropriate
manner.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which statement is correct about toilet training?
a. Bladder training is usually accomplished before bowel training.
b. Wanting to please the parent helps motivate the child to use the toilet.
c. Watching older siblings use the toilet confuses the child.
d. Children must be forced to sit on the toilet when first learning.
ANS: B
Voluntary control of the anal and urethral sphincters is achieved sometime after the child is
walking. The child must be able to recognize the urge to let go and to hold on. The child must
want to please parent by holding on rather than pleasing self by letting go. Bowel training
precedes bladder training. Watching older siblings provides role modeling and facilitates
imitation for the toddler. The child should be introduced to the potty chair or toilet in a
nonthreatening manner.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which characteristic best describes the gross motor skills of a 24-month-old child?
a. Skips and can hop in place on one foot
b. Rides tricycle and broad jumps
c. Jumps with both feet and stands on one foot momentarily
d. Walks up and down stairs and runs with a wide stance
ANS: D
The 24-month-old child can go up and down stairs alone with two feet on each step and runs
with a wide stance. Skipping and hopping on one foot are achieved by 4-year-old children.
Jumping with both feet and standing on one foot momentarily are achieved by 30-month-old
children. Tricycle riding and broad jumping are achieved at age 3.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. The parents of a newborn say that their toddler is aggressive toward the infant and has
commented the infant should “go back in mommy’s tummy”. Which is the nurse’s best reply?
“Let’s see if we can figure out why he hates the new baby.”
“That’s a strong statement to come from such a small boy.”
“Let’s refer him to counseling to work this hatred out. It’s not a normal response.”
“That is a normal response to the birth of a sibling. Let’s look at ways to deal with
this.”
a.
b.
c.
d.
ANS: D
The arrival of a new infant represents a crisis for even the best-prepared toddlers. They do not
hate or resent the infant; rather, they hate the changes that this additional sibling produces,
especially the separation from mother during the birth. This is a normal response.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
10. A toddler’s parent asks the nurse for suggestions on dealing with temper tantrums. Which is
the most appropriate recommendation?
Punish the child.
Leave the child alone until the tantrum is over.
Stay calm and ignore the behavior.
Explain to child that this is wrong.
a.
b.
c.
d.
ANS: C
The parent should be told that the best way to deal with temper tantrums is to ignore the
behaviors, provided that the actions are not dangerous to the child. Tantrums are common in
toddlers as the child becomes more independent and overwhelmed by increasingly complex
tasks. The parents and caregivers need to have consistent and developmentally appropriate
expectations. Punishment and explanations will not be beneficial. The parent’s presence is
necessary both for safety and to provide a feeling of control and security to the child when the
tantrum is over.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
11. A parent asks the nurse about negativism in toddlers. Which is the most appropriate
recommendation?
a. Punish the child.
b. Provide more attention.
c. Ignore the child who says “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.”
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
12. 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. Which would the nurse explain to the father?
This behavior is abnormal
Used as a way to exert unhealthy control
Regression is common at this age
Ritualism is common at this age
a.
b.
c.
d.
ANS: D
The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to
maintain sameness and reliability. It provides a sense of comfort to the toddler. It will dictate
certain principles in feeding practices, including rejecting a favorite food because it is served
in a different container. Ritualism is not indicative of a child who has unreasonable
expectations, but rather normal development. Toddlers use ritualistic behaviors to maintain
necessary structure in their lives. This is not regression, which is a retreat from a present
pattern of functioning.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. Developmentally, which would most children at age 12 months be able to do?
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
14. Which is the most effective way to clean a toddler’s teeth?
a. Child to brush regularly with a toothpaste of his or her choice
b. Parent to stabilize the chin with one hand and brush with the other
c. Parent to brush the mandibular occlusive surfaces, leaving the rest for the child
d. Parent to brush the front labial surfaces, leaving the rest for the child
ANS: B
For young children, the most effective cleaning of teeth is by the parents. Different positions
can be used if the child’s back is to the adult. The adult should use one hand to stabilize the
chin and the other to brush the child’s teeth. The child can participate in brushing, but for a
thorough cleaning, adult intervention is necessary.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
15. Which is the leading cause of death during the toddler period?
a. Unintentional injuries
b. Infectious diseases
c. Congenital disorders
d. Childhood diseases
ANS: A
Injuries are the single most common cause of death in children ages 1 through 4 years. This
represents the highest rate of death from injuries of any childhood age group except
adolescence. Infectious diseases and childhood diseases are less common causes of deaths in
this age group. Congenital disorders are the second leading cause of death in this age group.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
16. The nurse recommends to parents that peanuts are not a good snack food for toddlers. Which
is the nurse’s rationale for this action?
Low in nutritive value
High in sodium
Cannot be entirely digested
Can be easily aspirated
a.
b.
c.
d.
ANS: D
Foreign-body aspiration is common during the second year of life. Although they chew well,
this age child may have difficulty with large pieces of food, such as meat and whole hot dogs,
and with hard foods, such as nuts or dried beans. Peanuts have many beneficial nutrients, but
should be avoided because of the risk of aspiration in this age group. The sodium level may be
a concern, but the risk of aspiration is more important. Many foods pass through the
gastrointestinal tract incompletely undigested. This is not necessarily detrimental to the child.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
17. The parent of a 16-month-old toddler asks, “What is the best way to keep our son from getting
into our medicines at home?” The nurse’s best response is
a. “all medicines should be locked securely away.”
b. “the medicines should be placed in cabinets.”
c. “the child just needs to be taught not to touch medicines.”
d. “medicines should not be kept in the homes of small children.”
ANS: A
The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch
cabinets, and obtain access to high-security places. For medications, only a locked cabinet is
safe. Toddlers can climb by using furniture. High places are not a deterrent to an exploring
toddler. Toddlers are not able to generalize as dangerous all the different forms of medications
that may be available in the home. It is not feasible to not keep medicines in the homes of
small children. Many parents require medications for chronic illnesses. Parents must be taught
safe storage for their home and when they visit other homes.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment
18. Which play item would the nurse bring from the playroom to a hospitalized toddler in
isolation?
Small plastic Lego
Set of large plastic building blocks
Brightly colored balloon
Coloring book and crayons
a.
b.
c.
d.
ANS: B
Play objects for toddlers must still be chosen with an awareness of danger from small parts.
Large, sturdy toys without sharp edges or removable parts are safest. Large plastic blocks are
appropriate for a toddler in isolation. Small plastic toys such as Lego can cause choking or can
be aspirated. Balloons can cause significant harm if swallowed or aspirated. Coloring book
and crayons would be too advanced for a toddler.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which are characteristic of physical development of a 30-month-old child? (Select all that
apply.)
Birth weight has doubled.
Primary dentition is complete.
Voluntary control of urethral sphincter.
Anterior fontanel is open.
Left or right hand dominance is established.
a.
b.
c.
d.
e.
ANS: B, C
Usually by age 30 months, the primary dentition of 20 teeth is completed, and the child has
sphincter control in preparation for bowel and bladder control. Birth weight doubles at
approximately ages 5 to 6 months. The anterior fontanel closes at age 12 to 18 months. Birth
length is doubled around age 4. Left- or right-handedness is not established until about age 5.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which gross motor milestones would the nurse assess in an 18-month-old child? (Select all
that apply.)
Jumps in place with both feet
Takes a few steps on tiptoe
Throws ball overhand without falling
Pulls and pushes toys
Stands on one foot momentarily
a.
b.
c.
d.
e.
ANS: A, D
An 18-month-old child can jump in place with both feet, throw a ball overhand without
falling, and pull and push toys. Taking a few steps on tiptoe and standing on one foot
momentarily is not acquired until 30 months of age.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 12: Health Promotion of the Preschooler and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which would the nurse expect of a healthy 3-year-old child?
a. Jump rope
b. Ride a two-wheel bicycle
c. Skip on alternate feet
d. Balance on one foot for a few seconds
ANS: D
Three-year-olds are able to accomplish this gross motor skill. Jumping rope, riding a twowheel bicycle, and skipping on alternate feet are gross motor skills of 5-year-olds.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. In terms of fine motor development, which would 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. According to Piaget, which describes magical thinking common in preschool age children?
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 child’s 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 preschooler’s spiritual
development. Thinking that if the skin is broken, the child’s insides will come out is an
example of concrete thinking in development of body image.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which is descriptive of the preschooler’s 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 preschooler’s understanding, time has a relation with events such as “We’ll go outside
after lunch.” Preschoolers develop an abstract sense of time at age 3 years. Children can tell
time on a clock at age 7 years. Children do not fully understand use of time-oriented words
until age 6 years.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. A 4-year-old child who is hospitalized with a bacterial infection tells the nurse that he is sick
because he was “bad.” Which is the nurse’s best interpretation of this comment?
a. Sign of stress
b. Common at this age
c. Suggestive of maladaptation
d. Suggestive of excessive discipline at home
ANS: B
Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them
think they are directly responsible for events, making them feel guilty for things outside their
control. Children of this age show stress by regressing developmentally or acting out.
Maladaptation is unlikely. Telling the nurse that he is sick because he was “bad” does not
imply excessive discipline at home.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. A 4-year-old child tells the nurse that she does not want another blood sample drawn because
“I need all my insides, and I don’t want anyone taking them out.” Which is the nurse’s best
interpretation of this?
a. Child is being overly dramatic.
b. Child has a disturbed body image.
c. Preschoolers have poorly defined body 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which play is most typical of the preschool period?
a. Solitary
b. Parallel
c. Associative
d. Team
ANS: C
Associative play is group play in similar or identical activities but without rigid organization
or rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children
play in teams.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Why are imaginary playmates beneficial to the preschool child?
a. Take the place of social interactions
b. Take the place of pets and other toys
c. Become friends in times of loneliness
d. Accomplish what the child has already 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
9. 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. By which age would the nurse expect that most children could obey prepositional phrases
such as “under,” “on top of,” “beside,” and “behind”?
18 months
24 months
3 years
4 years
a.
b.
c.
d.
ANS: D
At 4 years, children can understand directional phrases. Children at 18 months, 24 months,
and 3 years are too young.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. Which is a useful skill that the nurse would expect a 5-year-old child to be able to master?
a. Tie shoelaces
b. Use knife to cut meat
c. Hammer a nail
d. Make change out of a quarter
ANS: A
Tying shoelaces is a fine motor task of 5-year-olds. Using a knife to cut meat is a fine motor
task of a 7-year-old. Hammering a nail and making change out of a quarter are fine motor and
cognitive tasks of an 8- to 9-year-old.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
12. 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 recommendation would
the nurse 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 ageappropriate and not dangerous behavior.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
14. Which accurately describes the speech of the preschool child?
a.
b.
c.
d.
Dysfluency in speech patterns is normal.
Sentence structure and grammatic usage are limited.
By age 5 years, child can be expected to have a vocabulary of about 1000 words.
Rate of vocabulary acquisition keeps pace with the degree of comprehension of
speech.
ANS: A
Dysfluency includes stuttering and stammering, a normal characteristic of language
development. Children speak in sentences of three or four words at age 3 to 4 years and eight
words by age 5 years. At 5 years, children have a vocabulary of 2100 words. Children often
gain vocabulary beyond degree of comprehension.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
15. Which injury prevention efforts are emphasized during the preschool period?
a. Constant vigilance and protection
b. Punishment for unsafe behaviors
c. Education for safety and potential hazards
d. Limitation of physical activities
ANS: C
Education for safety and potential hazards is appropriate for preschoolers because they can
begin to understand dangers. Constant vigilance and protection is not practical at this age
because preschoolers are becoming more independent. Punishment may make children scared
of trying new things. Limitation of physical activities is not appropriate.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment
16. Parents are concerned that their child is showing aggressive behaviors. Which suggestion
would the nurse make to the parents?
Supervise television viewing.
Ignore the behavior.
Punish the child for the behavior.
Accept the behavior if the child is male.
a.
b.
c.
d.
ANS: A
Television is also a significant source for modeling at this impressionable age. Research
indicates there is a direct correlation between media exposure, both violent and educational
media, and preschoolers exhibiting physical and relational aggression (Ostrov, Gentile, and
Crick, 2006). Therefore, parents should be encouraged to supervise television viewing. The
behavior should not be ignored because it can escalate to hyperaggression. The child should
not be punished because it may reinforce the behavior if the child is seeking attention. For
example, children who are ignored by a parent until they hit a sibling or the parent learn that
this act garners attention. The behavior should not be accepted from a male child; this is using
a “double standard” and aggression should not be equated with masculinity.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. Which snack would the nurse recommend parents offer to their slightly overweight preschool
child?
Carbonated beverage
10% fruit juice
Low fat milk
Whole milk
a.
b.
c.
d.
ANS: C
Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Low-fat
milk may be substituted, so the quantity of milk may remain the same while limiting fat intake
overall. Parents should be educated regarding non-nutritious fruit drinks, which usually
contain less than 10% fruit juice yet are often advertised as healthy and nutritious; sugar
content is dramatically increased and often precludes an adequate intake of milk by the child.
In young children, intake of carbonated beverages that are acidic or that contain high amounts
of sugar is also known to contribute to dental caries. Low fat milk should be substituted for
whole milk if the child is slightly overweight.
DIF: Cognitive Level: Apply
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.)
Think in abstract terms.
Less egocentrism developed.
Understand conservation of matter.
Use sentences of eight words.
Understands time better.
Comprehend another person’s perspective.
a.
b.
c.
d.
e.
f.
ANS: B, E
Children ages 3 to 4 years can give and follow simple commands and tell exaggerated stories.
Children cannot think abstractly at age 4 years. Conservation of matter is a developmental
task of the school-age child. Five-year-old children use sentences with eight words with all
parts of speech. A 4-year-old child cannot comprehend another’s perspective.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which toys would a nurse provide to promote imaginative play for a 3-year-old hospitalized
child? (Select all that apply.)
Plastic telephone
Hand puppets
Jigsaw puzzle (100 pieces)
Farm animals and equipment
Jump rope
a.
b.
c.
d.
e.
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 3year-old child.
DIF: Cognitive Level: Apply
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:
700
While limiting fat consumption, it is important to ensure diets contain adequate nutrients such
as calcium. The recommendation for daily calcium intake for children 1 to 3 years of age is
500 mg, and the recommendation for children 4 to 8 years of age is 800 mg.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 13: Health Problems of Toddlers and Preschoolers
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse suspects that a child has ingested some type of poison. Which clinical manifestation
would be most suggestive that the poison was a corrosive product?
Tinnitus
Disorientation
Stupor, lethargy, coma
Edema of lips, tongue, pharynx
a.
b.
c.
d.
ANS: D
Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of
aspirin ingestion. Corrosives do not act on the central nervous system (CNS).
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
2. The nurse who is caring for a preschool aged child who aspirated a small amount of paint
thinner knows which condition(s) may be diagnosed?
Hepatic dysfunction
Dehydration secondary to vomiting
Esophageal stricture and shock
Bronchitis and chemical pneumonia
a.
b.
c.
d.
ANS: D
Paint thinner is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose,
not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger.
Esophageal stricture is a late or chronic issue of hydrocarbon ingestion.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity
3. Which is a clinical manifestation of acetaminophen poisoning?
a. Hyperpyrexia
b. Hepatotoxicity
c. Hyperactivity
d. Drooling and inability to clear secretions
ANS: B
Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe
elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen
does not cause burning pain in stomach or pose an airway threat.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
4. What is a late symptom of acute acetylsalicylic acid poisoning?
a. Chemical pneumonitis
b. Hepatic damage
c. Retractions and grunting
d. Seizures
ANS: D
Hyperactivity, fever, confusion, seizures, renal and respiratory failure are late symptoms of
acute acetylsalicylic poisoning.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
5. The practitioner has ordered activated charcoal for a young child who ingested a large amount
of acetylsalicylic acid at home. 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. Mix in food such as mashed potatoes.
c. Give half of the solution, and then give the other half in 1 hour.
d. Mix with water to form a slurry.
ANS: D
Although the activated charcoal can be mixed with a flavorful beverage, it will be black and
resemble mud. When it is served in an opaque container, the child does not have any
preconceived ideas about its being distasteful. The nasogastric tube should be used only in
children without a gag reflex. The ability to see the charcoal solution may affect the child’s
desire to drink it. The child should be encouraged to drink the solution all at once.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
6. Which is the most frequent source of acute childhood lead poisoning?
a. Folk remedies
b. Unglazed lead pottery
c. Lead-based paint
d. Lead tainted ash
ANS: C
Lead-based paint in houses built before 1978 is the most frequent source of lead poisoning.
Some folk remedies and unglazed pottery may contain lead, but they are not the most frequent
source. Cigarette butts and ashes do not contain lead.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity
7. At which blood level is chelation therapy for lead poisoning initiated in a child?
a. 10 to 14 g/dl
b. 15 to 19 g/dl
c. 20 to 44 g/dl
d. 45 g/dl
ANS: D
Chelation therapy is initiated if the child’s blood level is greater than or equal to 45 g/dl. At 10
to 14 g/dl, the family should have lead-poisoning education and follow-up level. At 15 to 19
g/dl, the family should have lead-poisoning education and follow-up level but if it persists,
initiate environmental investigation. At 20 to 44 g/dl environmental investigation and lead
hazard control are necessary.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
8. A 3-month-old infant presents to the Emergency Department with subdural and retinal
hemorrhages but no external signs of trauma, and dies shortly after arriving. What would the
nurse suspect?
a. Plant poisoning
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.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
9. Which is probably the most important criterion on which to base the decision to report
suspected child abuse?
Inappropriate parental concern for the degree of injury
Absence of parents for questioning about child’s injuries
Inappropriate response of child
Incompatibility between the history and injury observed
a.
b.
c.
d.
ANS: D
Conflicting stories about the “accident” are the most indicative red flags of abuse.
Inappropriate response of caregiver or child may be present, but is subjective. Parents should
be questioned at some point during the investigation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
10. Which intervention would the nurse implement during the time a child is receiving calcium
EDTA chelation therapy?
Calorie counts
Strict intake and output
Telemetry monitoring
Glucose monitoring
a.
b.
c.
d.
ANS: B
Because calcium disodium edetate (EDTA) and lead are toxic to the kidneys, a nurse should
keep strict records of intake and output to monitor renal functioning. Adequate hydration is
essential during therapy because the chelates are excreted via the kidneys. Calorie counts,
telemetry, or contact isolation would not be nursing interventions appropriate for a child
undergoing chelation therapy.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
11. Which prescribed antidote would the nurse prepare to administer for a child who has
acetaminophen poisoning?
Naloxone (Narcan)
N-acetylcysteine (Mucomyst)
Flumazenil (Romazicon)
Digoxin immune Fab (Digibind)
a.
b.
c.
d.
ANS: B
Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen
poisoning, naloxone for opioid overdose, flumazenil (Romazicon) for benzodiazepine
(diazepam [Valium], midazolam [Versed]) overdose, and digoxin immune Fab (Digibind) for
digoxin toxicity.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. Which is common characteristics of those who sexually abuse children? (Select all that
apply.)
Pressure victim into secrecy
Are usually unemployed and unmarried
Typically a man whom the victim knows
Have many victims that are each abused once only
Typically have a prior criminal record
a.
b.
c.
d.
e.
ANS: A, C
Sex offenders may pressure the victim into secrecy regarding the activity as a “secret between
us” that other people may take away if they find out. The offender may be anyone, including
family members and persons from any level of society. Sex offenders are usually trusted
acquaintances of the victims and victims’ families. Many victims are abused many times over
a long period.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
2. A nurse is teaching parents methods to reduce lead levels in their home. Which would the
nurse include in the teaching? (Select all that apply.)
a. Plant bushes around the outside of the house.
b. Ensure your child eats regular 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 child’s diet contains sufficient iron and calcium.
ANS: A, B, E
Methods to reduce lead levels in homes include: planting bushes around the outside of the
house if soil is contaminated with lead, so children cannot play there; ensuring that children
eat regular meals because more lead is absorbed on an empty stomach; and ensuring that
children’s diets contain sufficient iron and calcium. Cold water should only be used for
drinking, cooking, and reconstituting powder infant formula. Hot water dissolves lead more
quickly than cold water and thus contains higher levels of lead. Do not use pottery or ceramic
ware that was inadequately fired or is meant for decorative use for food storage or service.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the correct sequence for emergency treatment of poisoning in a child. Provide
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.
ANS:
B, D, A, C
The initial step in treating poisonings is to assess the child, treat immediate life-threatening
conditions, and initiate cardiopulmonary resuscitation (CPR) if indicated. Terminating the
exposure to the toxic substance is the second step. Locating the poison for identification is the
third step. Preventing absorption of poison is the fourth step.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity
Chapter 14: Health Promotion of the School-Age Child and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which is the earliest age that puberty begins?
a. 9
b. 10
c. 11
d. 12
ANS: A
There is no universal age at which children assume the characteristics of prepubescence. The
first physiologic signs appear at about 9 years of age (particularly in girls) and are usually
clearly evident in 11- to 12-year-old children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. 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
Children who are ages 6 and 7 years know the rules and behaviors expected of them but do
not understand the reasons for these rules and behaviors. Young children do not believe that
standards of behavior come from within themselves, but that rules are established and set
down by others. Younger school-age children learn standards for acceptable behavior, act
according to these standards, and feel guilty when they violate them. Misfortunes and
accidents are viewed as punishment for bad acts.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
3. 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. An 8-year-old girl tells the nurse that she has cancer because God is punishing her for “being
bad.” How would the nurse interpret this statement?
A common belief at this age
A belief that forms the basis for most religions
Suggestive of excessive family pressure
Suggestive of a failure to develop a conscience
a.
b.
c.
d.
ANS: A
Children at this age may view illness or injury as a punishment for a real or imagined
misdeed. The belief in divine punishment is common for an 8-year-old child.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
5. 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. 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. How would this be interpreted?
Behavior that encourages bullying and sexism
Behavior that reinforces poor peer relationships
Characteristic of typical social development at this age
Characteristic of children who later are at risk for membership in gangs
a.
b.
c.
d.
ANS: C
One of the outstanding characteristics of middle childhood is the creation of formalized
groups or clubs. Peer-group identification and association are essential to a child’s
socialization. Poor relationships with peers and a lack of group identification can contribute to
bullying. A boys-only club does not have a direct correlation with later gang activity.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which statement supports the idea that older children have a need for conformity in group
play?
a.
b.
c.
d.
Individuality in play is better tolerated than at earlier ages.
Knowing the rules of a game gives an important sense of belonging.
They like to invent games, making up the rules as they go.
Team play helps children learn the universal importance of competition and
winning.
ANS: B
Play involves increased physical skill, intellectual ability, and fantasy. Children form groups
and cliques and develop a sense of belonging to a team or club. At this age, children begin to
see the need for rules. Conformity and ritual permeate their play. Their games have fixed and
unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children
learn about competition and the importance of winning, an attribute highly valued in the
United States.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
8. The nurse recognizes the involvement of which group greatly increases the success of anti-
bullying efforts toward those that are bullies?
The whole family
School administration
School psychologists
Family primary practitioner
a.
b.
c.
d.
ANS: A
School personnel such as administration and psychologists play an important role in
implementing anti-bullying interventions, and the PCP may implement therapies; however,
research has recognized that involving the whole family in anti-bullying programs greatly
increases success.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
9. Which is characteristic of dishonest behavior in older children
a. Cheating during games is now more common.
b. Lying results from the inability to distinguish between fact and fantasy.
c. They may steal because their sense of property rights is limited.
d. They may lie to meet expectations set by others that they have been unable to
attain.
ANS: D
Older school-age children may lie to meet expectations set by others to which they have been
unable to measure up. Cheating usually becomes less frequent as the child matures. In this age
group, children are able to distinguish between fact and fantasy. Young children may lack a
sense of property rights; older children may steal to supplement an inadequate allowance, or it
may be an indication of serious problems.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. A 9-year-old girl often comes to the school nurse complaining of stomach pains, and her
teacher reports she has been aggressive in the classroom. How would the nurse interpret this
behavior?
a. A sign of stress
b. A developmental delay
c. A physical problem
d. A lack of adjustment to school
ANS: A
Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in
eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to early
behaviors. This child is exhibiting signs of stress.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
11. 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 children’s 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.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
12. A child has an evulsed a tooth and will not put the tooth back in the socket. Which medium
would the nurse instruct the parents to place the tooth in for transport to the dentist?
a. Cold milk
b. Cold water
c. Warm salt water
d. Dry, clean jar
ANS: A
An evulsed tooth should be placed in a suitable medium for transplant, either cold milk or
saliva (under the child or parent’s tongue). Cold milk is a more suitable medium for transport
than cold water, warm salt water, or a dry, clean jar.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
13. Which would the nurse recognize when asked to present sex education to fifth graders?
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. 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 only if the bicycle has an extra-large seat.”
ANS: D
Children should not ride double. Most injuries result from falls. The most important aspect of
bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major
cause of bicycle-related fatalities. The child should always wear a properly fitted helmet
approved by the US Consumer Product Safety Commission and should replace the helmet at
least every 5 years.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
15. When teaching injury prevention during the school-age years, which would the nurse include?
a. Promote the fear of strangers.
b. Basic rules of water safety.
c. Avoidance of microwave cooking.
d. Emphasize the negative aspects of competitive sports.
ANS: B
Water safety instruction is an important source of injury prevention at this age. The child
should be taught to swim, select safe and supervised places to swim, swim with a companion,
check for sufficient water depth before diving, and use an approved flotation device. Teach
stranger safety, not fear of strangers. This includes instructing children to not go with
strangers, not wear personalized clothing in public places, tell parents if anyone makes child
feel uncomfortable, and say “no” in uncomfortable situations. Teach child safe cooking.
Caution against engaging in hazardous sports such as those involving trampolines.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
16. 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 schoolwork.”
c. “We will plan a trip to the library as often as possible.”
d. “We will expect our child to make all As in school.”
ANS: C
General guidelines for parents to help their child in school include sharing an interest in
reading. The library should be used frequently, and books the child is reading should be
discussed. Hobbies should be encouraged. The parents should not expect all As. They should
focus on growth more than grades.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. A school nurse is teaching dental health practices to a group of sixth-grade children. How
often would the nurse recommend the children brush their teeth?
Twice a day; after breakfast and dinner
Three times a day; after breakfast, lunch and dinner
After meals only
After meals, after snacks, and at bedtime
a.
b.
c.
d.
ANS: D
Teeth should be brushed after meals, after snacks, and at bedtime. Children who brush their
teeth frequently and become accustomed to the feel of a clean mouth at an early age usually
maintain the habit throughout life. Twice a day, three times a day, or after meals would not be
often enough.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. Parents of a 11-year-old child ask the clinic nurse, “How many hours of sleep should our child
get?” The nurse would respond with which number to represent hours per night of sleep
suggested for this age group?
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which describes the cognitive abilities of school-age children? (Select all that apply.)
a. Have developed the ability to reason abstractly
b. Are capable of scientific reasoning and formal logic
c. Developed the ability to understand relational terms and concepts
d. Have a mastery of the concept of conservation
e. Have a steady reduction in egocentricity
ANS: C, D, E
In Piaget’s stage of concrete operations, children have the ability to group and sort and make
conceptual decisions. Children cannot reason abstractly and logically until late adolescence.
Making judgments based on what they reason to making judgments based on what they see is
not a developmental skill.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
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.)
Achieve personal goals over group goals.
Learn complex rules.
Experience competition.
Learn about division of labor.
Intellectual growth.
a.
b.
c.
d.
e.
ANS: B, D, E
Team play helps stimulate cognitive growth because children are called on to learn many
complex rules, make judgments about those rules, plan strategies, and assess the strengths and
weaknesses of members of their own team and members of the opposing team. Team play can
also contribute to children’s social, intellectual, and skill growth. Children work hard to
develop the skills needed to become team members, to improve their contribution to the
group, and to anticipate the consequences of their behavior for the group. Team play teaches
children to modify or exchange personal goals for goals of the group; it also teaches them that
division of labor is an effective strategy for attaining a goal.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 15: Health Promotion of the Adolescent and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. What is the initial indication of puberty in most girls?
a. Menarche
b. Growth spurt
c. Growth of pubic hair
d. Breast development
ANS: D
In most girls, the initial indication of puberty is the appearance of breast buds, an event known
as thelarche. The usual sequence of secondary sex characteristic development in girls is breast
changes, rapid increase in height and weight, growth of pubic hair, appearance of axillary hair,
menstruation, and abrupt deceleration of linear growth.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. By which age should concerns about pubertal delay be considered in boys?
a. 11 years
b. 12 years
c. 14 years
d. 15 years
ANS: C
Concerns about pubertal delay should be considered for boys who exhibit no enlargement of
the testes or scrotal changes from 131/2 to 14 years. Ages 12 to 131/2 years is too young for
initial concern.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. According to Erikson, which psychosocial task is developing in adolescence?
a. Intimacy
b. Identity
c. Initiative
d. Independence
ANS: B
Traditional psychosocial theory holds that the developmental crises of adolescence lead to the
formation of a sense of identity. Intimacy is the developmental stage for early adulthood.
Independence is not one of Erikson’s developmental stages.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Adolescents are in which stage of cognitive development?
a. Formal operations
b. Concrete operations
c. Conventional thought
d. Postconventional thought
ANS: A
Cognitive thinking culminates with capacity for abstract thinking. This stage, the period of
formal operations, is Piaget’s fourth and last stage. Concrete operations usually occur between
ages 7 and 11 years. Conventional and postconventional thought refers to Kohlberg’s stages of
moral development.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which aspect of cognition develops during adolescence?
a. Can perceive and act on long-range options
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
6. 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?
Adolescents dislike their parents.
Adolescents no longer need parental control.
They provide adolescents with a feeling of belonging.
They promote a sense of individuality in adolescents.
a.
b.
c.
d.
ANS: C
The peer group serves as a strong support to teenagers, providing them with a sense of
belonging and a sense of strength and power. During adolescence, the parent-child
relationship changes from one of protection-dependency to one of mutual affection and
quality. Parents continue to play an important role in the personal and health-related decisions.
The peer group forms the transitional world between dependence and autonomy.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
7. An adolescent boy tells the nurse that he has recently had homosexual feelings. What
knowledge should the nurse’s response be based on?
This indicates the adolescent is homosexual.
This indicates the adolescent will become homosexual as an adult.
The adolescent should be referred for psychotherapy.
Sexual orientation encompasses several dimensions.
a.
b.
c.
d.
ANS: D
These adolescents are at increased risk for health-damaging behaviors, not because of the
sexual behavior itself, but because of society’s reaction to the behavior. The nurse’s first
priority is to give the young man permission to discuss his feelings about this topic, knowing
that the nurse will maintain confidentiality, appreciate his feelings, and remain sensitive to his
need to talk about the topic. In recent studies among self-identified gay, lesbian, and bisexual
adolescents, many of the adolescents report changing self-labels one or more times during
their adolescence. An assessment must be made about any risks to himself or others. If these
do not exist, the adolescent needs a supportive person to talk with.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Health Promotion and Maintenance
8. The school nurse tells adolescents in the clinic that confidentiality and privacy will be
maintained unless a legal duty arises. How should this practice be interpreted?
Not appropriate in a school setting
Never appropriate because adolescents are minors
Important in establishing trusting relationships
Suggestive that the nurse is meeting his or her own needs
a.
b.
c.
d.
ANS: C
Health professionals who work with adolescents should consider adolescents’ increasing
independence and responsibility while maintaining privacy and ensuring confidentiality.
However, in some circumstances, such as self-destructive behavior or maltreatment by others,
they are not able to maintain confidentiality. Confidentiality and privacy are necessary to build
trust with this age group. The nurse must be aware of the limits placed on confidentiality by
local jurisdiction.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Management of Care
9. 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
10. A young adolescent boy tells the nurse he “feels gawky.” How should the nurse explain why
this occurs in adolescents?
Growth of the extremities and neck precedes growth in other areas
Growth is in the trunk and chest
The hip and chest breadth increases
The growth spurt occurs earlier in boys than it does in girls
a.
b.
c.
d.
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
11. A nurse is reviewing hormone changes that occur during adolescence. What is the hormone
responsible for the growth of beard, mustache, and body hair in the male?
Estrogen
Pituitary
Androgen
Progesterone
a.
b.
c.
d.
ANS: C
Beard, mustache, and body hair on the chest, upward along the linea alba, and sometimes on
other areas (e.g., back and shoulders) appears in males and is androgen-dependent. Estrogen
and progesterone are produced by the ovaries in the female and do not contribute to body hair
appearance in the male. The pituitary hormone does not have any relationship to body hair
appearance in the male.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
12. Adolescents may experiences many “mood swings” throughout the day. How should the nurse
interpret this behavior?
Requires a referral to a mental health counselor
Requires some further lab testing
It is normal behavior
Related to feelings of depression
a.
b.
c.
d.
ANS: C
Adolescents vacillate in their emotional states between considerable maturity and childlike
behavior. One minute they are exuberant and enthusiastic; the next minute they are depressed
and withdrawn. Because of these mood swings, adolescents are frequently labeled as unstable,
inconsistent, and unpredictable, but the behavior is normal. The behavior would not require a
referral to a mental health counselor or further lab testing. The mood swings do not indicate
depression.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
13. 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
14. What should the nurse expect the health care provider to recommend for a 14-year-old child
who has never had chickenpox?
One dose of the varicella vaccination
Two doses of the varicella vaccination 4 weeks apart
One dose of the varicella immune globulin
No vaccinations—the child is past the age to receive it
a.
b.
c.
d.
ANS: B
All adolescents should also be assessed for previous history of varicella infection or
vaccination. Vaccination with the varicella vaccine is recommended for those with no
previous history; for those with no previous infection or history, the varicella vaccine may be
given in two doses 4 or more weeks apart to adolescents 13 years or older. The varicella
immune globulin is given to immunosuppressed children exposed to chickenpox to boost
immunity; it is only temporary. The varicella vaccination should be given to adolescents, no
matter the age, who have not had chickenpox as a child.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
15. Which immunization should adolescents receive annually?
a. DTaP (tetanus, diphtheria, acellular pertussis)
b. MMR (measles, mumps, rubella)
c. Hepatitis B
d. Influenza
e. MCV4 (meningococcal)
ANS: D
The DTaP (tetanus, diphtheria, acellular pertussis) vaccine is recommended for adolescents 11
to 18 years old who have not received a tetanus booster (Td) or DTaP dose and have
completed the childhood DTaP/DTP series. Meningococcal vaccine (MCV4) should be given
to adolescents 11 to 12 years of age with a booster dose at age 16 years. Annual influenza
vaccination with either the live attenuated influenza vaccine or trivalent influenza vaccine is
recommended for all children and adolescents. The adolescent, previously up to date on
vaccinations, would have received the MMR and hepatitis B as a child.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. What is the leading causes of death in the adolescent age group? (Select all that apply.)
a. Cancer
b. Suicide
c. Drug overdoses
d. Motor vehicle crashes
e. Homicide
ANS: B, D, E
Forty percent of all adolescent deaths in the United States are the result of motor vehicle
accidents. Drownings, firearms, and drug overdoses are major concerns in adolescence but are
not the most common cause of death.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
2. The nurse should teach the adolescent that the long-term effects of tanning can cause which
conditions? (Select all that apply.)
Phototoxic reactions
Increased number of moles
Premature aging
Striae
Increased risk of skin cancer
a.
b.
c.
d.
e.
ANS: A, C, E
Long-term effects of tanning include premature aging of the skin, increased risk of skin
cancer, and, in susceptible individuals, phototoxic reactions. There has been no correlation to
an increase in moles or striae (streaks or stripes on the skin, usually on the abdomen)
development.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. Place in order the sequence of maturational changes for girls. Begin with the first change seen,
sequencing to the last change. Provide answer in using lowercase letters, separated by
commas (e.g., A, B, C, D, E).
a. Growth of pubic hair
b. Rapid increase in height and weight
c. Breast changes
d. Menstruation
e. Appearance of axillary hair
ANS:
C, B, A, E, D
The usual sequence of maturational changes for girls is breast changes, rapid increase in
height and weight, growth of public hair, appearance of axillary hair, and then menstruation,
which usually begins 2 years after the first signs.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 16: Health Problems of School-Age Children and Adolescents
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which statement is true about smoking in adolescence?
a. Smoking is related to other high-risk behaviors.
b. Smoking will not continue unless peer pressure continues.
c. Smoking is less common when the adolescent’s parent(s) smokes.
d. Smoking among adolescents is becoming more prevalent.
ANS: A
Cigarettes are considered a gateway drug. Teenagers who smoke are 11.4 times more likely to
use an illicit drug. Teenagers begin smoking for a variety of reasons, such as imitation of adult
behavior, peer pressure, imitation of behaviors portrayed in movies and advertisements, and a
desire to control weight. The absence of peer pressure alone will not stop smoking. Teenagers
who do not smoke usually have parents and friends who do not smoke or who oppose
smoking. The percentage of young people who report current cigarette use and frequent
cigarette use has declined significantly.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. An adolescent asks the nurse what causes primary dysmenorrhea. The nurse’s response would
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. It arises from the release of prostaglandins.
ANS: D
The exact etiology of primary dysmenorrhea is debated. Overproduction of uterine
prostaglandins has been implicated, as has overproduction of vasopressin. Dysmenorrhea is
not known to be inherited. Excessive estrogen has not been implicated in the etiology. It has a
physiologic cause. Women with dysmenorrhea have higher prostaglandin levels.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. An adolescent girl asks the school nurse if an over-the-counter nonsteroidal anti-inflammatory
drug (NSAID)is a good choice to treat her dysmenorrhea. The nurse’s response would be
based on which statement?
a. Aspirin is the drug of choice for the treatment of dysmenorrhea.
b. Over-the-counter NSAIDs are rarely strong enough to provide adequate pain relief.
c. NSAIDs are effective because of their analgesic effect.
d. NSAIDs are effective because they inhibit prostaglandins, leading to reduction in
uterine activity.
ANS: D
First-line therapy for adolescents with dysmenorrhea is NSAIDs. This group of drugs blocks
the formation of prostaglandins. NSAIDs, not aspirin, are the drugs of choice in
dysmenorrhea. NSAIDs are potent anti-inflammatory agents that inhibit prostaglandin.
Although NSAIDs have analgesic effects, the mechanism of action in dysmenorrhea is most
likely the antiprostaglandin effect.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
4. A 14-year-old boy and his parents are concerned about bilateral breast enlargement. The
nurse’s discussion of this would be based on which statement?
This occurs frequently during puberty.
This is usually caused by Klinefelter syndrome.
Administration of estrogen effectively reduces gynecomastia.
Administration of testosterone effectively reduces gynecomastia.
a.
b.
c.
d.
ANS: A
The male breast responds to hormonal changes. Some degree of bilateral or unilateral breast
enlargement occurs frequently in boys during puberty. Although individuals with Klinefelter
syndrome can have gynecomastia, it is not a common cause for male breast enlargement.
Estrogen is not a therapy for gynecomastia. Administration of testosterone has no benefit for
gynecomastia and may aggravate the condition.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. An adolescent tells the school nurse she has a confirmed pregnancy, her last menstrual cycle
was 4 months ago, and she smokes cigarettes. Which is the priority nursing action?
a. Notify her parents
b. Refer for prenatal care
c. Explain the importance of not smoking
d. Discuss dietary needs for adequate fetal growth
ANS: B
Teenage girls and their unborn children are at greater risk for complications during pregnancy
and delivery. With improved therapies, the mortality for teenage pregnancy is decreasing, but
the morbidity is high. A pregnant teenager needs careful assessment by the nurse to determine
the level of social support available to her and possibly her partner. Guidance from the adults
in her life would be invaluable, but confidentiality should be maintained. Although it is
important to explain the importance of not smoking and to discuss dietary needs for adequate
fetal growth, because of her potential for having a high-risk pregnancy, she will need a
comprehensive prenatal program to minimize maternal-fetal complications.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. A sexually active female adolescent asks the nurse about the contraceptive Depo-Provera.
Which would the nurse explain regarding the contraceptive?
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 Depo-Provera, require daily administration of medication by mouth.
Norplant, not Depo-Provera, provides long-term continuous protection for up to 5 years.
Postcoital contraception, not Depo-Provera, prevents pregnancy if given within 72 hours of
unprotected sex.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. A nurse is conducting a class for adolescent girls about pelvic inflammatory disease (PID) and
would include which teaching point?
PID is a genetic disease.
PID cannot be treated.
PID can have devastating effects on the reproductive tract.
PID can cause serious defects in future children of affected adolescents.
a.
b.
c.
d.
ANS: C
PID is a major concern because of its devastating effects on the reproductive tract. Short-term
complications include abscess formation in the fallopian tubes, whereas long-term
complications include ectopic pregnancy, infertility, and dyspareunia. PID is an infection of
the upper female genital tract, most commonly caused by sexually transmitted infections but it
is not sexually transmitted to another person. PID can be treated by treating the underlying
cause. There is a possibility of ectopic pregnancy but not birth defects in children.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. Which symptoms would 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
b. Tachycardia
c. Heat intolerance
d. Lowered body temperature
ANS: D
Symptoms of anorexia nervosa include lower body temperature, severe weight loss, decreased
blood pressure, dry skin, brittle nails, altered metabolic activity, and presence of lanugo hair.
Amenorrhea, rather than dysmenorrhea, and cold intolerance are manifestations of anorexia
nervosa. Bradycardia, rather than tachycardia, may be present.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is teaching the parents of a child recently diagnosed with ADHD who has been
prescribed methylphenidate (Ritalin). Which would the nurse include in teaching about the
side effects of methylphenidate?
a. “Your child may feel embarrassed by having to leave class to take medications.”
b. “You may see an decrease in your child’s appetite.”
c. “Your child may experience daytime sleepiness.”
d. “You may see a decrease in your child’s blood pressure.”
ANS: B
Nervousness is one of the common side effects of Ritalin. Decreased appetite with subsequent
weight loss, insomnia, and increased blood pressure are other common side effects.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
10. Which is an important consideration when the nurse is discussing enuresis with the parents of
a young child?
Enuresis is more common in girls than in boys.
Enuresis is neither inherited nor has a familial tendency.
Organic causes that may be related to enuresis should be considered first.
Psychogenic factors that cause enuresis persist into adulthood.
a.
b.
c.
d.
ANS: C
Organic causes that may be related to enuresis should be ruled out before psychogenic factors
are considered. Enuresis is more common in boys than in girls and has a strong familial
tendency. Psychogenic factors may influence enuresis, but it is doubtful that they are
causative.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. The nurse is assisting the family of a child with a history of encopresis. Which would be
included in the nurse’s discussion with this family?
a. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
b. Instruct the parents that the child will probably need to have daily enemas.
c. Suggest the use of stimulant cathartics weekly.
d. Reassure the family that most problems are resolved successfully, with some
relapses during periods of stress.
ANS: D
Children may be unaware of a prior sensation and unable to control the urge once it begins.
They may be so accustomed to bowel accidents that they are unable to smell or feel it. Family
counseling is directed toward reassurance that most problems resolve successfully, although
relapses during periods of stress are possible. Sitting the child on the toilet is not
recommended because it may intensify the parent-child conflict. Enemas may be needed for
impactions, but long-term use prevents the child from assuming responsibility for defecation.
Stimulant cathartics may cause cramping that can frighten the child.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. A mother calls the school nurse saying that her daughter has developed a school phobia. She
has been out of school 3 days. The nurse’s recommendations would include which
intervention?
a. Immediate return to school is essential.
b. Explain to the child that this is the last day she can stay home.
c. Determine the cause of phobia before returning the child to school.
d. Seek professional counseling before forcing the child to return to school.
ANS: A
The primary goal is to return the child to school. Parents must be convinced gently, but firmly,
that immediate return is essential and that it is their responsibility to insist on school
attendance. The longer the child is permitted to stay out of school, the more difficult it will be
for the child to reenter. Trying to find the cause of phobia will only delay the return to school
and inhibit the child’s ability to cope. Professional counseling is recommended if the problem
persists, but the child’s return to school should not wait for the counseling.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
13. Parents have a concern that their child is depressed. The nurse relates that which characteristic
best describes children with depression?
Increased range of affective response
Preoccupation with need to perform well in school
Change in appetite, resulting in weight loss or gain
Tendency to prefer play instead of schoolwork
a.
b.
c.
d.
ANS: C
Physiologic characteristics of children with depression include change in appetite resulting in
weight loss or gain, nonspecific complaints of not feeling well, alterations in sleeping pattern,
insomnia or hypersomnia, and constipation. Children who are depressed have sad facial
expressions with absence or diminished range of affective response. These children withdraw
from previously enjoyed activities and engage in solitary play or work with a lack of interest
in play. A lack of interest is seen in doing homework or achieving in school, resulting in lower
grades in children who are depressed.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
14. Which is the most significant factor in distinguishing those who commit suicide from those
who make suicidal attempts or threats?
Social isolation
Level of stress
Degree of depression
Desire to punish others
a.
b.
c.
d.
ANS: A
Social isolation is a significant factor in distinguishing adolescents who will kill themselves
from those who will not. It is also more characteristic of those who complete suicide than of
those who make attempts or threats. Level of stress, degree of depression, and desire to punish
others are contributing factors in suicide, but they are not the most significant factor in
distinguishing those who complete suicide from those who attempt suicide.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
15. An adolescent girl tells the nurse that she is very suicidal, and the nurse asks her whether she
has a specific plan. Asking this would be considered
an appropriate part of the assessment.
not a critical part of the assessment.
suggestive that the adolescent needs a plan.
an inappropriate nursing assessment.
a.
b.
c.
d.
ANS: A
Routine health assessments of adolescents should include questions that assess the presence of
suicidal ideation or intent. Questions such as, “Have you ever developed a plan to hurt
yourself or kill yourself?” should be part of that assessment. Adolescents who express suicidal
feelings and have a specific plan are at particular risk and require further assessment and
constant monitoring. The information about having a plan is an essential part of the
assessment and greatly affects the treatment plan.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
16. An adolescent has been diagnosed with Chlamydia infection. Which medication would the
nurse expect to be prescribed for this condition?
Ceftriaxone (Rocephin) IM
Azithromycin (Zithromax) PO
Acyclovir (Zovirax) PO
Penicillin G benzathine (Bicillin) IV
a.
b.
c.
d.
ANS: B
Azithromycin is used to treat Chlamydia. The patient should be rescreened in 3 to 4 months.
Ceftriaxone is used to treat gonorrhea, acyclovir is used to suppress genital herpes simplex
virus, and penicillin G benzathine is used to treat syphilis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
17. When is isotretinoin (Accutane) indicated for the treatment of acne during adolescence?
a. The acne has not responded to other treatments.
b. The adolescent is or may become pregnant.
c. The adolescent is unable to give up foods causing acne.
d. Frequent washing with antibacterial soap has been unsuccessful.
ANS: A
Isotretinoin is reserved for severe cystic acne that has not responded to other treatments.
Isotretinoin has teratogenic effects and should never be used when there is a possibility of
pregnancy. No correlation exists between foods and acne. Antibacterial soaps are ineffective.
Frequent washing with antibacterial soap is not a recommended therapy for acne.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. The nurse is caring for an adolescent brought to the Emergency Department with acute drug
toxicity from cocaine. Data collection would include which information? (Select all that
apply.)
a. Mode of administration
b. Amount of drug taken
c. Function the drug plays in the adolescent’s life
d. Adolescent’s level of interest in rehabilitation
e. time of ingestion
ANS: A, B, E
When the drug is questionable or unknown, every effort must be made to determine the type,
amount of drug taken, the mode and time of administration, and factors relating to the onset of
presenting symptoms. The actual content of most street drugs is highly questionable.
Pharmacologic agents should be administered with caution, except for the narcotic antagonists
in case of suspected opioid use. The function the drug plays in the adolescent’s life and the
adolescent’s level of interest in rehabilitation are important considerations in the long-term
management during the non-acute stage.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
2. A nurse is recommending strategies to a group of school-age children for prevention of
obesity. Which would the nurse include? (Select all that apply.)
Eat breakfast daily.
Limit fruits and vegetables.
Have frequent family meals with parents present.
Eat frequently at restaurants.
Limit screen time to 2 hours a day.
a.
b.
c.
d.
e.
ANS: A, C
The nurse should counsel school-age children to eat breakfast daily, have mealtimes with
family, and limit television viewing to 2 hours a day to prevent obesity. Fruits and vegetables
should be consumed in the recommended quantities, and eating at restaurants should be
limited.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which strategies would the school nurse recommend implementing in the classroom for a
child with 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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 17: Impact of Chronic Illness, Disability, or End-of-Life Care on the Child and
Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The parents of a special health needs child is displaying an approach behavior when doing
which of the following?
Is unable to adjust to a progression of the disease or condition
Anticipates future problems and seeks guidance and answers
Looks for new cures without a perspective toward possible benefit
Fails to recognize the seriousness of the child’s condition despite physical evidence
a.
b.
c.
d.
ANS: B
The parents who anticipate future problems and seek guidance and answers are demonstrating
approach behaviors. They are demonstrating positive actions in caring for their child. Being
unable to adjust to a progression of the disease or condition, looking for new cures without a
perspective toward possible benefit, and failing to recognize the seriousness of a child’s
condition despite physical evidence are avoidance behaviors. The parents are moving away
from adjustment (and toward maladaptation) in the crisis of a child with chronic illness or
disability.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
2. The initial response from a parent when learning of a chronic or complex health condition is
shock, which is followed by which response?
Denial
Guilt and self-accusation
Social reintegration
Acceptance of the child’s limitations
a.
b.
c.
d.
ANS: B
For most families, the adjustment phase is accompanied by several responses. Guilt, selfaccusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic
illness or disability often is met with intense emotion, characterized by shock and denial.
Social reintegration and acceptance of the child’s limitations are the culmination of the
adjustment process.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
3. The nurse observes that a seriously ill child passively accepts all painful procedures. Which
would the nurse recognize this child is most likely experiencing?
a. A sense of hopefulness
b. A sense of chronic sorrow
c. A belief that procedures are a deserved punishment
d. A 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 goal-directed actions. This child would actively
participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves over
time. It is usually evident in the parents, not in the child. A child who believes that procedures
are an important part of care would actively participate in care. Nursing interventions should
be used to minimize the pain.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
4. The nurse comes into the room of a child who was just diagnosed with a chronic disability,
and the child’s parents begin to yell at the nurse about a variety of concerns. Which is the
nurse’s best response?
a. “What is really wrong?”
b. “Being angry is only natural.”
c. “Yelling at me will not change things.”
d. “I will come back when you settle down.”
ANS: B
Parental anger after the diagnosis of a child with a chronic disability is a common response.
One of the most common targets for parental anger is members of the staff. The nurse should
recognize the common response of anger to the diagnosis and allow the family to vent. “What
is really wrong?”/“Yelling at me will not change things”/“I will come back when you settle
down” will place the parents on the defensive and not facilitate communication.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Psychosocial Integrity
5. Which is a characteristic of chronic sorrow often experience by parents who have a
chronically ill child?
Lack of acceptance of the child’s limitation
Lack of available support to prevent sorrow
Periods of intensified sorrow when experiencing anger and guilt
Periods of intensified sorrow and loss that occur in waves over time
a.
b.
c.
d.
ANS: D
Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time.
The sorrow is in response to the recognition of the child’s limitations. The family should be
assessed in an ongoing manner to provide appropriate support as the needs of the family
change. The sorrow is not preventable. The chronic sorrow occurs during the reintegration and
acknowledgment stage.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Psychosocial Integrity
6. Which intervention will encourage a sense of autonomy in a toddler with disabilities?
a. Avoid separation from family during hospitalizations.
b. Encourage independence in as many areas as possible.
c. Expose child to pleasurable experiences as much as possible.
d. Help parents learn special care needs of their child.
ANS: B
Encouraging the toddler to be independent encourages a sense of autonomy. The child can be
given choices about feeding, dressing, and diversional activities, which will provide a sense of
control. Avoiding separation from family during hospitalizations, and helping parents learn
special care needs of their child should be practiced as part of family-centered care. It does not
necessarily foster autonomy. Exposing the child to pleasurable experiences, especially sensory
ones, is a supportive intervention. It does not promote autonomy.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
7. The feeling of guilt that the child “caused” the disability or illness is especially critical in
which child?
Toddler
Preschooler
School-age child
Adolescent
a.
b.
c.
d.
ANS: B
Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or
disability or are being punished for wrongdoings. Toddlers are focused on establishing their
autonomy. The illness will foster dependence. The school-age child will have limited
opportunities for achievement and may not be able to understand limitations. Adolescents face
the task of incorporating their disabilities into their changing self-concept.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
8. Which is the most appropriate nursing intervention to promote normalization in a school-age
child with a chronic illness?
Give the child as much control as possible.
Ask the child’s peer to make the child feel normal.
Convince the child that nothing is wrong with him or her.
Explain to parents that family rules for the child do not need to be the same as for
healthy siblings.
a.
b.
c.
d.
ANS: A
The school-age child who is ill may be forced into a period of dependency. To foster
normalcy, the child should be given as much control as possible. It is unrealistic to expect one
individual to make the child feel normal. The child has a chronic illness. It would be
unacceptable to convince the child that nothing is wrong. The family rules should be similar
for each of the children in a family. Resentment and hostility can arise if different standards
are applied to each child.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
9. Which nursing intervention would the nurse include to help the siblings of a child with special
needs cope?
a. Explain to the siblings that embarrassment is unhealthy
b. Encourage the parents not to expect siblings to help them care for the child with
special needs
c. Provide information to the siblings about the child’s condition only as they request
it
d. Suggest to the parents ways of showing gratitude to the siblings who help care for
the child with special needs
ANS: D
The presence of a child with special needs in a family will change the family dynamic.
Siblings may be asked to take on additional responsibilities to help the parents to care for the
child. The parents should show gratitude, such as an increase in allowance, special privileges,
and verbal praise. Embarrassment may be associated with having a sibling with a chronic
illness or disability. Parents must be able to respond in an appropriate manner without
punishing the sibling. The parents may need assistance with the care of the child. Most
siblings are positive about the extra responsibilities. The siblings need to be informed about
the child’s condition before a nonfamily member does so. The parents do not want the siblings
to fantasize about what is wrong with the child.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
10. The parents of a child born with disabilities ask the nurse for advice about discipline. Which
information about discipline would the nurse’s response include?
It is essential for normal development.
It is too difficult to implement with a special-needs child.
It is not needed unless the child becomes problematic.
It is best achieved with punishment for misbehavior.
a.
b.
c.
d.
ANS: A
Discipline is essential for the child. It provides boundaries on which to test out their behavior
and teaches them socially acceptable behaviors. The nurse should teach the parents ways to
manage the child’s behavior before it becomes problematic. Punishment is not effective in
managing behavior.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
11. A 16-year-old with a chronic illness has recently become rebellious and is taking risks such as
missing doses of his medication. Which is the best explanation for this behavior?
Needs more discipline
Needs more socialization with peers
This is part of normal adolescence
This is how he is asking for more parental control
a.
b.
c.
d.
ANS: C
Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
12. At which age do most children have an adult concept of death as being inevitable, universal,
and irreversible?
4 to 5 years
6 to 7 years
9 to 10 years
12 to 13 years
a.
b.
c.
d.
ANS: C
By age 9 to 11 years, children have an adult concept of death. They realize that it is inevitable,
universal, and irreversible.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
13. A school-age child is diagnosed with a life-threatening illness, and the parents want to protect
their child from knowing the seriousness of the illness. Which would the nurse tell the
parents?
a. This will help the child cope effectively by denial.
b. This attitude is helpful to give parents time to cope.
c. Terminally ill children know when they are seriously ill.
d. Terminally ill children usually choose not to discuss the seriousness of their illness.
ANS: C
The child needs honest and accurate information about the illness, treatments, and prognosis.
Children, even at a young age, realize that something is seriously wrong and that it involves
them. The nurse should help the parents understand the importance of honesty.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
14. When considering palliative care for a young child with a life-threatening illness, which is an
important consideration?
The family is included in the decision to shift the goals of treatment.
The decision must be made by the health professionals involved in the child’s care.
The family needs to understand that palliative care takes place in the home.
The decision should not be communicated to the family because it will encourage a
sense of hopelessness.
a.
b.
c.
d.
ANS: A
When the child reaches the terminal stage, the nurse and physician should explore the family’s
wishes. The family should help decide what interventions will occur as they plan for their
child’s death.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
15. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still
“hear” the child’s voice and have trouble sleeping. How would the nurse interpret these
feelings?
a. These are normal grief responses.
b. The pain of the loss is usually less by this time.
c. These grief responses are more typical of the early stages of grief.
d. This grieving is essential until the pain is gone and the child is gradually forgotten.
ANS: A
These are normal grief responses. The process of grief work is lengthy.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
16. A nurse is planning palliative care for a child with severe pain. Which would the nurse expect
to be prescribed for pain relief?
Opioids as needed
Opioids on a regular schedule
Distraction and relaxation techniques
Nonsteroidal anti-inflammatory drugs
a.
b.
c.
d.
ANS: B
Pain medications, for children in palliative care, should be given on a regular schedule, and
extra doses for breakthrough pain should be available to maintain comfort. Opioid drugs such
as morphine should be given for severe pain, and the dose should be increased as necessary to
maintain optimal pain relief. Techniques such as distraction, relaxation techniques, and guided
imagery should be combined with drug therapy to provide the child and family strategies to
control pain. Nonsteroidal anti-inflammatory drugs are not sufficient to manage severe pain
for children in palliative care.
DIF: Cognitive Level: Apply
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.)
Refuses to agree to treatment
Shares burden of disorder with others
Verbalizes possible loss of child
Withdraws from outside world
Punishes self because of guilt and shame
a.
b.
c.
d.
e.
ANS: A, D, E
A parent who refuses to agree to treatment, withdraws from the outside world, and punishes
self because of guilt and shame is exhibiting avoidance coping behaviors. A parent who shares
the burden of disorder with others and verbalizes possible loss of child is exhibiting approach
coping behaviors.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Psychosocial Integrity
2. Which are appropriate statements the nurse would make to parents after the death of their
child? (Select all that apply.)
“We feel so sorry that we couldn’t save your child.”
“Your child isn’t suffering anymore.”
“I know how you feel.”
“You’re feeling all the pain of losing a child.”
“You are still young enough to have another baby.”
a.
b.
c.
d.
e.
ANS: A, D
By saying, “We feel so sorry that we couldn’t save your child,” the nurse is expressing
personal feeling of loss or frustration, which is therapeutic. Stating, “You’re feeling all the
pain of losing a child,” focuses on a feeling, which is therapeutic. The statement, “Your child
isn’t suffering anymore,” is a judgmental statement, which is nontherapeutic. “I know how
you feel” and “You’re still young enough to have another baby” are statements that give
artificial consolation and are nontherapeutic.
DIF: Cognitive Level: Apply
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.)
Develops optimism
Feels different and withdraws
Accepts physical limitations
Is irritable and moody
Finds achievement in compensatory intellectual pursuits
a.
b.
c.
d.
e.
ANS: A, C, E
Adaptive coping patterns used by children with special needs include seeking support and
developing optimism. Maladaptive behaviors are seeing themselves as different and
withdrawing and becoming irritable, moody, and beginning to act out.
DIF: Cognitive Level: Understand
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.)
Body feels warm
Tactile sensation decreasing
Speech becomes rapid
Change in respiratory pattern
Difficulty swallowing
a.
b.
c.
d.
e.
ANS: B, D, E
Physical signs of approaching death include: tactile sensation beginning to decrease, a change
in respiratory pattern, and difficulty swallowing. Even though there is a sensation of heat the
body feels cool, not warm, and speech becomes slurred, not rapid.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
Chapter 18: Impact of Cognitive or Sensory Impairment on the Child and Family
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A young child has an intelligence quotient (IQ) of 45. The nurse would document this finding
as
a.
b.
c.
d.
mild cognitive impairment.
moderate cognitive impairment.
severe cognitive impairment.
profound cognitive impairment.
ANS: B
Moderate cognitive impairment IQs range between 35 and 55. The lower limit of normal
intelligence is approximately 70. Individuals with IQs of 50 to 70 are considered to have mild
cognitive impairment but educable. An IQ of 20 to 40 results in severe cognitive impairment.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
2. When would children with cognitive impairment be referred for stimulation and educational
programs?
As young as possible
As soon as they have the ability to communicate in some way
At age 3 years, when schools are required to provide services
At age 5 or 6 years, when schools are required to provide services
a.
b.
c.
d.
ANS: A
The child’s education should begin as soon as possible. Considerable evidence exists that
early intervention programs for children with disabilities are valuable for cognitively impaired
children. The early intervention may facilitate the child’s development of communication
skills. States are encouraged to provide early intervention programs from birth under Public
Law 101-476, the Individuals with Disabilities Education Act.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
3. Which would be the major consideration when selecting toys for a child who is cognitively
impaired?
Safety
Age appropriateness
Ability to provide exercise
Skill and dexterity
a.
b.
c.
d.
ANS: A
Safety is the primary concern in selecting recreational and exercise activities for all children.
This is especially true for children who are cognitively impaired. Age appropriateness, the
ability to provide exercise, and the ability to teach useful skills should all be considered in the
selection of toys, but safety is of paramount importance.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
4. Which are appropriate interventions to facilitate socialization of the cognitively impaired
child?
Provide age-appropriate toys and play activities.
Provide peer experiences, such as scouting, when older.
Avoid exposure to strangers who may not understand cognitive development.
Emphasize mastery of physical skills because they are delayed more often than
verbal skills.
a.
b.
c.
d.
ANS: B
The acquisition of social skills is a complex task. Children of all ages need peer relationships.
Parents should enroll the child in preschool. When older, they should have peer experiences
similar to those of other children such as group outings, Boy and Girl Scouts, and Special
Olympics. It is important to provide age-appropriate toys and play activities, but peer
interactions will facilitate social development. Parents should expose the child to strangers so
that the child can practice social skills. Verbal skills are delayed more than physical skills.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
5. The nurse is discussing sexuality with the parents of an adolescent girl with moderate
cognitive impairment. Which would the nurse consider with this topic?
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. Contraceptive protection should not be considered an option.
ANS: C
Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment.
A well-defined, concrete code of conduct with specific instructions for handling certain
situations should be laid out for the adolescent. Permanent contraception by sterilization
presents moral and ethical issues and may have psychological effects on the adolescent. It
may be prohibited in some states. The adolescent needs to have practical sexual information
regarding physical development and contraception. Cognitively impaired individuals may
desire to marry and have families. The adolescent needs to be protected from individuals who
may make intimate advances.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
6. Which is the most common congenital anomaly associated with Down Syndrome?
a. Pernicious anemia
b. Pyloric stenosis
c. Heart malformation
d. Hip dysplasia
ANS: C
Congenital heart malformations, primarily septal defects, are the most common congenital
anomaly in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are
not frequent congenital anomalies associated with Down syndrome.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. A new nurse is orienting to the unit and displays an understanding of Fragile X Syndrome
when using which descriptor?
A chromosomal defect affecting females only
A chromosomal defect that follows the pattern of X-linked recessive disorders
The second most common genetic cause of cognitive impairment
The most common cause of noninherited cognitive impairment
a.
b.
c.
d.
ANS: C
Fragile X syndrome is the second most common cause of cognitive impairment after Down
syndrome. Fragile X primarily affects males, and follows the inheritance pattern of X-linked
dominant with reduced penetrance. This is in distinct contrast to the classic X-linked recessive
pattern in which all carrier females are normal, all affected males have symptoms of the
disorder, and no males are carriers.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Distortion of sound and problems in discrimination are characteristic of which type of hearing
loss?
Conductive
Sensorineural
Mixed conductive-sensorineural
Central auditory imperceptive
a.
b.
c.
d.
ANS: B
Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to
the inner ear structures or the auditory nerve. It results in the distortion of sounds and
problems in discrimination. Conductive hearing loss involves mainly interference with
loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination
of both sensorineural and conductive loss. Central auditory imperceptive hearing loss includes
all hearing losses that do not demonstrate defects in the conduction or sensory structures.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Adaptation: Reduction of Risk Potential
9. 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?
Conductive
Sensorineural
Mixed conductive-sensorineural
Central auditory imperceptive
a.
b.
c.
d.
ANS: A
Conductive or middle-ear hearing loss is the most common type. It results from interference
of transmission of sound to the middle ear, most often from recurrent otitis media.
Sensorineural, mixed conductive-sensorineural, and central auditory imperceptive are less
common types of hearing loss.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. The nurse would suspect a hearing impairment in an infant who demonstrates which
behavior?
Absence of the Moro reflex
Absence of babbling by age 7 months
Lack of eye contact when being spoken to
Lack of gesturing to indicate wants after age 15 months
a.
b.
c.
d.
ANS: B
The absence of babbling or inflections in voice by age 7 months is an indication of hearing
difficulties. The absence of the Moro reflex and eye contact when being spoken to does not
indicate a hearing impairment. The child with hearing impairment uses gestures rather than
vocalizations to express desires at this age.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. Which is an implanted ear prosthesis for children with sensorineural hearing loss?
a. Hearing aid
b. Cochlear implant
c. Auditory implant
d. Amplification device
ANS: B
Cochlear implants are surgically implanted, and they provide a sensation of hearing for
individuals who have severe or profound hearing loss of sensorineural origin. Hearing aids
and amplification devices are external devices for enhancing hearing. Auditory implants do
not exist.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. A nurse is preparing a teaching session for parents on prevention of childhood hearing loss.
Which is the most common cause of hearing impairment in children?
a. Auditory nerve damage
b. Congenital ear defects
c. Congenital rubella
d. Chronic otitis media
ANS: D
Chronic otitis media is the most common cause of hearing impairment in children. It is
essential that appropriate measures be instituted to treat existing infections and prevent
recurrences. Auditory nerve damage, congenital ear defects, and congenital rubella are rarer
causes of hearing impairment.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. The refractive disorder where light rays fall in front of the retina is referred to as
a. myopia.
b. amblyopia.
c. cataract.
d. glaucoma.
ANS: A
Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not at
distance. Amblyopia, or lazy eye, is reduced visual acuity in one eye. A cataract is opacity of
the lens of the eye. Glaucoma is a group of eye diseases characterized by increased intraocular
pressure.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
14. A father calls the emergency department nurse saying that his daughter’s eyes burn after
getting some dishwasher detergent in them. The nurse should recommend which action before
the child is transported to the Emergency Department for evaluation?
a. Keep eyes closed.
b. Apply cold compresses.
c. Irrigate eyes copiously with tap water for 20 minutes.
d. Prepare a normal saline solution (salt and water) and irrigate eyes for 20 minutes.
ANS: C
The first action is to flush the eyes with clean tap water. This will rinse the detergent from the
eyes. Keeping eyes closed and applying cold compresses may allow the detergent to do
further harm to the eyes during transport. Normal saline is not necessary. The delay can allow
the detergent to cause continued injury to the eyes.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. The mother of a 13-month-old child states, “My child does not make noises like ‘da’ or ‘na’
like my sister’s baby, who is only 9 months old.” Which statement by the nurse would be most
appropriate to make?
a. “I am going to request a referral to a hearing specialist.”
b. “You should not compare your child to your sister’s child.”
c. “I think your child is fine, but we will check again in 3 months.”
d. “You should ask other parents what noises their children made at this age.”
ANS: A
By 11 months of age a child should be making well-formed syllables such as “da” or “na” and
should be referred to a specialist if not. “You should not compare your child to your sister’s
child,” “I think your child is fine, but we will check again in 3 months,” and “You should ask
other parents what noises their children made at this age,” are not appropriate statements to
make to the parent.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. Parents of a child with Down syndrome ask the nurse about techniques for introducing solid
food to their 8-month-old child’s diet. The nurse would give the parents which priority
instruction?
a. It is too early to add solids; the parents should wait for 2 to 3 months.
b. A small but long, straight-handled spoon should be used to push the food toward
the back and side of the mouth.
c. If the child thrusts the food out, the feeding should be stopped.
d. Solids should be offered only three times a day.
ANS: B
Down syndrome children have a protruding tongue which can interfere with feeding,
especially of solid foods. Parents need to know that the tongue thrust is not an indication of
refusal to feed but a physiologic response. Parents are advised to use a small but long,
straight-handled spoon to push the food toward the back and side of the mouth. If food is
thrust out, it should be re-fed. Six months is the time to introduce solid foods to a child, so
waiting 2 to 3 months is inappropriate. Small frequent feedings should be initiated to prevent
the child from tiring. Three times a day is too infrequent.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
17. A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The
nurse would plan which priority intervention when caring for the child?
Maintain a structured routine and keep stimulation to a minimum.
Place child in a room with a roommate of the same age.
Maintain frequent touch and eye contact with the child.
Take the child frequently to the playroom to play with other children.
a.
b.
c.
d.
ANS: A
Providing a structured routine for the child to follow is a key in the management of ASD.
Decreasing stimulation by using a private room, avoiding extraneous auditory and visual
distractions, and encouraging the parents to bring in possessions the child is attached to may
lessen the disruptiveness of hospitalization. Because physical contact often upsets these
children, minimum holding and eye contact may be necessary to avoid behavioral outbursts.
Children with ASD need to be introduced slowly to new situations, with visits with staff
caregivers kept short whenever possible. The playroom would be too overwhelming with new
people and situations and should not be a priority of care.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. The diagnostic criteria for autism include delayed or abnormal functioning in which areas?
(Select all that apply.)
a. Social communication
b. Parallel play
c.
d.
e.
f.
Gross motor development
Growth below the 5th percentile for height and weight
Symbolic or imaginative play
Social interaction
ANS: A, C, E, F
These are three of the areas in which autistic children may show delayed or abnormal
functioning: language as used in social communication, symbolic or imaginative play, and
social interaction. Parallel play is typical play of toddlers and is usually not affected. Gross
motor development and growth below the 5th percentile for height and weight are usually not
characteristic of autism.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which assessment findings are consistent with 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, E
The assessment findings of Down syndrome include high arched narrow palate, protruding
tongue, and transverse palmar creases. The fingers are stubby and the muscle tone is
hypotonic, not hypertonic.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. A nurse is instructing a nursing assistant on techniques to facilitate lipreading with a hearing-
impaired child who lip reads. Which techniques would the nurse include? (Select all that
apply.)
a. Speak at eye level.
b. Stand at a distance from the child.
c. Speak words in a loud tone.
d. Use facial expressions while speaking.
e. Keep sentences short.
ANS: A, D, E
To facilitate lipreading for a hearing-impaired child who can lip read, the speaker should be at
eye level, facing the child directly or at a 45-degree angle. Facial expressions should be used
to assist in conveying messages, and the sentences should be kept short. The speaker should
stand close to the child, not at a distance, and using a loud tone while speaking will not
facilitate lipreading.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Safe and Effective Care: Management of Care
Chapter 19: Family-Centered Care of the Child During Illness and Hospitalization
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A nurse is caring for three toddlers and one preschooler. Which represents the major stressor
of hospitalization for these four patients?
Separation anxiety
Loss of control
Fear of bodily injury
Fear of pain
a.
b.
c.
d.
ANS: A
The major stressor for children from infancy through the preschool years is separation anxiety,
also called anaclitic depression. This is a major stressor of hospitalization. Loss of control,
fear of bodily injury, and fear of pain are all stressors associated with hospitalization.
However, separation from family is a primary stressor in this age group.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which is the expected reaction from a hospitalized preschool child who is in isolation?
a. Sees it as a punishment
b. A threat to child’s 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is a common initial reaction of parents to illness or injury and hospitalization of their
child?
a. Anger
b. Indifference
c. Depression
d. Helplessness
ANS: D
Recent research has identified common themes among parents whose children were
hospitalized, including feeling an overall sense of helplessness, questioning the skills of staff,
accepting the reality of hospitalization, needing to have information explained in simple
language, dealing with fear, coping with uncertainty, and seeking reassurance from caregivers.
Anger or guilt is usually the second reaction stage. Fear, anxiety, and frustrations also are
common feelings. Parents may finally react with some form of depression related to the
physical and emotional exhaustion associated with a hospitalized child.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
4. The clinic nurse overhears school-age siblings tell their 6-year-old sister who is chronically ill,
“It isn’t fair that you get everything just because you are sick”. Which is the nurse’s best
assessment of this situation?
a. The siblings are immature and probably spoiled.
b. Jealousy is a common reaction to the illness or hospitalization of a sibling.
c. Family has ineffective coping mechanisms to deal with chronic illness.
d. The siblings need to better understand their sister’s illness and needs.
ANS: B
Siblings experience loneliness, fear, and worry, as well as anger, resentment, jealousy, and
guilt. The siblings experience stress equal to that of the hospitalized child. There is no
evidence that the family has maladaptive coping mechanisms.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
5. Which is an appropriate nursing intervention to minimize separation anxiety in a hospitalized
toddler?
Provide for privacy
Encourage parents to room-in
Explain procedures and routines
Encourage contact with children the same age
a.
b.
c.
d.
ANS: B
A toddler experiences separation anxiety secondary to being separated from the parents. To
avoid this, the parents should be encouraged to room in as much as possible. Maintaining
routines and ensuring privacy are helpful interventions, but they would not substitute for the
parents. Encouraging contact with children the same age would not substitute for having the
parents present.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Four-year-old Brian appears to be upset by hospitalization. Which is an appropriate
intervention?
Let him know it is all right to cry.
Give him time to gain control of himself.
Show him how other children are cooperating.
Tell him what a big boy he is to be so quiet.
a.
b.
c.
d.
ANS: A
Crying is an appropriate behavior for the upset preschooler. The nurse provides support
through physical presence. Giving the child time to gain control is appropriate, but the child
must know that crying is acceptable. The preschooler does not engage in competitive
behaviors.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
7. An 8-year-old is being admitted to the hospital from the emergency department with an injury
from falling off her bicycle. Which will help her in her adjustment to the hospital?
Explain hospital schedules to her, such as mealtimes.
Use terms such as “honey” and “dear” to show a caring attitude.
Explain when parents can visit and why siblings cannot come to see her.
Orient her parents, because she is young, to her room and hospital facility.
a.
b.
c.
d.
ANS: A
School-age children need to have control of their environment. The nurse should offer
explanations or prepare the child for those experiences that are unavailable. The nurse should
refer to the child by the preferred name. Explaining when parents can visit and why siblings
cannot come to see her is telling the child all of the limitations, not helping her adjust to the
hospital. At the age of 8 years, the child should be oriented to the environment along with the
parents.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
8. A five-year-old patient tells the nurse that she “needs a Band-Aid” where she had an injection.
Which is the best nursing action?
Apply a Band-Aid.
Ask her why she wants a Band-Aid.
Explain why a Band-Aid is not needed.
Show her that the bleeding has already stopped.
a.
b.
c.
d.
ANS: A
Children at this age group still fear that their insides may leak out at the injection site. Provide
the Band-Aid. No explanation should be required. The nurse should be prepared to apply a
small Band-Aid after the injection.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development
9. The parents of a hospitalized 3-year-old tell the nurse that they are going to buy her “a lot of
new toys, because she will be in the hospital.” The nurse’s reply would be based on an
understanding of which concept?
a. New toys make hospitalization easier.
b. New toys are usually better than older ones for children of this age.
c. At this age, children often need the comfort and reassurance of familiar toys from
home.
d. Buying new toys for a hospitalized child is a maladaptive way to cope with
parental guilt.
ANS: C
Parents should bring favorite items from home to be with the child. Young children associate
inanimate objects with people who are significant in their lives. The favorite items will
comfort and reassure the child. Because the parents left the objects, the preschooler knows the
parents will return. New toys will not serve the purpose of familiar toys and objects from
home. The parents may experience some guilt as a response to the hospitalization, but there is
no evidence that it is maladaptive.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. An 18-month-old has just been admitted with croup. His parent is tearful and tells the nurse,
“This is all my fault. I should have taken him to the doctor sooner so he wouldn’t have to be
here.” Which is appropriate in the care plan for this parent who is experiencing guilt?
a. Assist parent to understand this is a typical response to stress.
b. Explain to the parent that the illness is not serious.
c. Encourage the parent to maintain a sense of control.
d. Assess further why the parent has excessive guilt feelings.
ANS: A
Guilt is a common response of parents when a child is hospitalized. They may blame
themselves for the child’s illness or for not recognizing it soon enough. The nurse should
clarify the nature of the problem and reassure parents that the child is being cared for. Croup is
a potentially serious illness. The nurse should not minimize the parent’s feelings. It would be
difficult for the parent to maintain a sense of control while the child is seriously ill. No further
assessment is indicated at this time; guilt is a common response for parents.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
11. A 14-year-old boy is being admitted to the hospital for an appendectomy. Which roommate
would the nurse assign with this patient?
A 4-year-old boy post-appendectomy surgery
A 6-year-old boy with pneumonia
A 15-year-old boy admitted with a vasoocclusive sickle cell crisis
A 12-year-old boy with cellulitis
a.
b.
c.
d.
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 postappendectomy is too young, and the child with pneumonia is too young and possibly has an
infectious process. The 12-year-old boy with cellulitis is the right age, but he has an infection
(cellulitis).
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
12. 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 would be
expected about separation anxiety?
a. “I wish my parents could spend the night with me while I am in the hospital.”
b. “I think I would like for my siblings to visit me but not my friends.”
c. “I hope my friends don’t forget about visiting me.”
d. “I will be embarrassed if my friends come to the hospital to visit.”
ANS: C
Loss of peer-group contact may pose a severe emotional threat to an adolescent because of
loss of group status, so friends visiting are an important aspect of hospitalization for an
adolescent. Most adolescents do not need a parent to spend the night during hospitalization
and sometimes view the hospitalization as a welcome event. Adolescents would be more
concerned about friends visiting than siblings. Adolescents want visitors to keep control and
maintain social status among their group of peers.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
13. A nurse is preparing to complete an admission assessment on a 2-year-old child who is sitting
on the parent’s lap. Which technique would 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 parent’s lap.
d. Ask the child to stand by the parent while completing the exam.
ANS: C
The nurse should complete the exam while the child is on the parent’s lap. For young children,
particularly infants and toddlers, preserving parent–child contact is the best means of
decreasing the need for or stress of restraint. The entire physical examination can be done in a
parent’s lap with the parent hugging the child for procedures such as an otoscopic
examination. Placing the child in the crib, taking the child to the exam room, or asking the
child to stand by the parent would separate the child from the parent and cause anxiety.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
14. A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports
difficulty in going to sleep at night. Which intervention would 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 child’s routine is establishing a daily
schedule. This approach is most suitable for non–critically ill school-age and adolescent
children who have mastered the concept of time. It involves scheduling the child’s day to
include all those activities that are important to the child and nurse, such as treatment
procedures, schoolwork, exercise, television, playroom, and hobbies. The school-age child
with osteomyelitis would benefit from a schedule similar to the one followed at home.
Requesting a prescription for a sleeping pill would be inappropriate and allowing the child to
stay up late and sleep late would not be keeping the child in a routine followed at home.
Passive activities in the morning and interactive activities at bedtime should be reversed; it
would be better to keep the child active in the morning hours and plan quiet activities at
bedtime.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
15. A previously “potty-trained” 30-month-old child has reverted to wearing diapers while
hospitalized, and the nurse recognizes this as normal because of which reason?
Is a typical reaction to stress.
Developmental delays occur because of the hospitalization.
The child is experiencing urinary urgency because of hospitalization.
The child was too young to be “potty-trained.”
a.
b.
c.
d.
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A nurse in the emergency department is assessing a 5-year-old child with symptoms of
pneumonia and a fever of 102 F. Which intervention can the nurse implement to promote a
sense of control for the child?
a. None; this is an emergency and the child should not participate in care.
b. Allow the child to hold the digital thermometer while taking the child’s blood
pressure.
c. Ask the child if it is OK to take a temperature in the ear.
d. Have parents wait in the waiting room.
ANS: B
The nurse should allow the child to hold the digital thermometer while taking the child’s
blood pressure. Unless an emergency is life threatening, children need to participate in their
care to maintain a sense of control. Because emergency departments are frequently hectic,
there is a tendency to rush through procedures to save time. However, the extra few minutes
needed to allow children to participate may save many more minutes of useless resistance and
uncooperativeness during subsequent procedures. The child may not give permission, if asked,
for a procedure that is necessary to be performed. It is better to give choices such as, “Which
ear do you want me to do your temperature in?” instead of, “Can I take your temperature?”
Parents should remain with their child to help with decreasing the child’s anxiety.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which are the benefits of therapeutic play for a hospitalized child? (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 child’s feelings.
d. The child can deal with concerns and feelings.
e. Gives the child a structured play environment.
ANS: B, C, D
Play is an effective, nondirective modality for helping children deal with their concerns and
fears, and at the same time, it often helps the nurse gain insights into children’s needs and
feelings. Play and other expressive activities provide one of the best opportunities for
encouraging emotional expression, including the safe release of anger and hostility.
Nondirective play that allows children freedom for expression can be tremendously
therapeutic. Play therapy is a structured therapy that helps disturbed children. It should not be
confused with therapeutic play.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity
2. A child is being discharged from an ambulatory care center after an inguinal hernia repair.
Which discharge interventions would the nurse implement? (Select all that apply.)
Discuss dietary restrictions.
Hold any analgesic medications until the child is home.
Send a pain scale home with the family.
Suggest the parents fill the prescriptions on the way home.
Discuss complications that may occur, and steps to take if they do.
a.
b.
c.
d.
e.
ANS: A, C, E
The discharge interventions a nurse should implement when a child is being discharged from
an ambulatory care center should include dietary restrictions, being very specific and giving
examples of “clear fluids” or what is meant by a “full liquid diet.” The nurse should give
specific information on pain control and send a pain scale home with the family. All
complications that may occur after an inguinal hernia repair should be discussed with the
parents. The pain medication, as prescribed, should be given before the child leaves the
building and prescriptions should be filled and given to the family before discharge.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. A child is being admitted to the intensive care unit (ICU) and the parents are with the child.
Which creates stressors for children and parents in ICUs? (Select all that apply.)
Equipment noise
Privacy
Caring behavior by the nurse
Unfamiliar smells
Sleep deprivation
a.
b.
c.
d.
e.
ANS: A, B, D, E
The ICU can create physical and environmental stressors for children and their families.
Equipment noise (monitors, suction equipment, telephones, computers), unfamiliar smells
(alcohol, adhesive remover, body odors), and sleep deprivation all are stressors found in the
ICU. Privacy as opposed to no privacy and a caring nurse as opposed to unkind or thoughtless
comments from staff help reduce the stressors of the ICU.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
4. Which would the nurse document as complementary or alternative medical practices? (Select
all that apply.)
Use of acetaminophen (Tylenol) for fever
Administration of chamomile tea at bedtime
Hypnotherapy for relief of pain
Acupressure to relieve headaches
Cool mist vaporizer at the bedside for “stuffiness”
a.
b.
c.
d.
e.
ANS: B, C, D
When conducting an assessment, the nurse should inquire about the use of complementary or
alternative medical practices. Administration of chamomile tea at bedtime, hypnotherapy for
relief of pain, and acupressure to relieve headaches are complementary or alternative medical
practices. Using Tylenol for fever relief and a cool mist vaporizer at the bedside to reduce
“stuffiness” are not considered complementary or alternative medical practices.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 20: Pediatric Nursing Interventions and Skills
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. In addition to an increased temperature, which is an early sign of malignant hyperthermia?
a. Apnea
b. Bradycardia
c. Muscle rigidity
d. Decreased blood pressure
ANS: C
Early signs of malignant hyperthermia include tachycardia, increasing blood pressure,
tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia.
Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased blood
pressure, not decreased blood pressure, is characteristic of malignant hyperthermia.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which is an appropriate intervention to encourage food and fluid intake in a hospitalized
child?
a. Force the child to eat and drink to combat caloric losses.
b. Discourage participation in non-eating activities until caloric intake is sufficient.
c. Administer large quantities of flavored fluids at frequent intervals and during
meals.
d. Give high-quality foods and snacks whenever the child expresses hunger.
ANS: D
Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods
such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and
cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the
behavior as a control mechanism. Large quantities of fluid may decrease the child’s hunger
and further inhibit food intake.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
3. A 3-year-old child still has a fever of 102associated with a viral illness even after a dose of
acetaminophen two hours ago. The nurse’s action would be based on which statement?
Fevers such as this are common with viral illnesses.
Seizures are common in children when antipyretics are ineffective.
Fever over 102 F indicates greater severity of illness.
Fever over 102 F indicates a probable bacterial infection.
a.
b.
c.
d.
ANS: A
Most fevers are of brief duration, with limited consequences, and are viral. Little evidence
supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in
temperature nor its response to antipyretics indicates the severity or etiology of infection.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as
acetaminophen (Tylenol). Which would the nurse explain about antipyretics?
a. They may cause malignant hyperthermia
b. They may cause febrile seizures
c. They are of no value in treating hyperthermia
d. They are of limited value in treating hyperthermia
ANS: C
Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already
normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy
that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics
do not cause seizures and are of no value in hyperthermia.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
5. A 7-year-old who is about to undergo a venipuncture wants her mother to hold her. Which
information would the nurse include in her response to the child’s request?
It is unsafe.
It is helpful to relax the child.
It is against hospital policy.
It is unnecessary because of child’s age.
a.
b.
c.
d.
ANS: B
The mother’s preference for assisting, observing, or waiting outside the room should be
assessed along with the child’s preference for parental presence. The child’s choice should be
respected. This will most likely help the child through the procedure. If the mother and child
agree, then the mother is welcome to stay. Her familiarity with the procedure should be
assessed and potential safety risks identified (mother may sit in chair). Hospital policies
should be reviewed to ensure that they incorporate family-centered care. The child should
determine whether parental support is necessary.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. Urine testing for specific gravity and glucose are ordered on a 6-month-old infant, and the
nurse will prepare for which action?
a. Apply a urine-collection bag to the perineal area.
b. Tape a small medicine cup to the inside of the diaper.
c. Aspirate urine from cotton balls inside the diaper with a syringe.
d. Aspirate urine from a superabsorbent disposable diaper with a syringe.
ANS: A
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly
from the diaper. If diapers with absorbent material are used, place a small gauze dressing or
cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For
frequent urine sampling, the collection bag would be too irritating to the child’s skin. It is not
feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the
cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. Which is an important nursing consideration when performing a bladder catheterization on a
10-year-old boy?
a. Clean technique, not standard precautions, is needed.
b. Insert 2% lidocaine lubricant on the meatus.
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. The Allen test is performed as a precautionary measure before which procedure?
a. Heel stick
b. Venipuncture
c. Arterial puncture
d. Lumbar puncture
ANS: C
The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial
puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or
lumbar punctures.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. Which action is recommended when preparing to do a heel stick on a neonate?
a. Apply cool, moist compresses.
b. Apply a tourniquet to the ankle.
c. Elevate the foot for 5 minutes.
d. Warm the heel for 3 minutes
ANS: D
Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10
minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood
collection more difficult. A tourniquet is used to constrict superficial veins. It will have an
insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot
available for collection.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. When liquid medication is given to a crying 10-month-old infant, which approach minimizes
the possibility of aspiration?
a. Administer the medication with an oral syringe placed along the side of the infant’s
tongue.
b. Administer the medication as rapidly as possible with the infant securely
restrained.
c. Mix the medication with the infant’s regular formula or juice and administer by
bottle.
d. Keep the child upright with the nasal passages blocked for a minute after
administration.
ANS: A
Administer the medication with a syringe without needle placed along the side of the infant’s
tongue. The contents are administered slowly in small amounts, allowing the child to swallow
between deposits. Medications should be given slowly to avoid aspiration. The medication
should be mixed with only a small amount of food or liquid. If the child does not finish
drinking or eating, it is difficult to determine how much medication was consumed. Essential
foods also should not be used. Holding the child’s nasal passages will increase the risk of
aspiration.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
11. Guidelines for intramuscular administration of medication in school-age children include
which action?
Inject medication as rapidly as possible.
Insert needle quickly, using a dart like motion.
Penetrate skin immediately after cleansing site, before skin has dried.
Have child stand, if possible, and if child is cooperative.
a.
b.
c.
d.
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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
12. Which is considered an advantage of a Hickman-Broviac catheter?
a.
b.
c.
d.
No need to keep exit site dry
Easy to use for self-administered infusions
Heparinized only monthly and after each infusion
No limitations on regular physical activity, including swimming
ANS: B
The Hickman-Broviac catheter has several benefits, including that it is easy to use for selfadministered infusions. The exit site must be kept dry to decrease risk of infection. The
Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted
because of risk of infection.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. When teaching a mother how to administer eye drops, where would the nurse tell her to place
them?
In the conjunctival sac that is formed when the lower lid is pulled down
Carefully under the eye lid while it is gently pulled upward
On the sclera while the child looks to the side
Anywhere as long as drops contact the eye’s surface
a.
b.
c.
d.
ANS: A
The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is
applied to this area. The medication should not be administered directly on the eyeball.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. A 2-year-old child comes to the emergency department with dehydration and hypovolemic
shock. Which best explains why an intraosseous infusion is started?
It is less painful for small children.
Rapid venous access is not possible.
Antibiotics must be started immediately.
Long-term central venous access is not possible.
a.
b.
c.
d.
ANS: B
In situations in which rapid establishment of systemic access is vital and venous access is
hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous
infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local
anesthetics and systemic analgesics are given. Antibiotics could be given when vascular
access is obtained. Long-term central venous access is time-consuming, and intraosseous
infusion is used in an emergency situation.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15. Which would the nurse do when caring for a child with an intravenous infusion?
a. Use a macrodropper to facilitate reaching the prescribed flow rate.
b. Avoid restraining the child to prevent undue emotional stress.
c. Change the insertion site every 24 hours.
d. Observe the insertion site frequently for signs of infiltration.
ANS: D
The nursing responsibility for IV therapy is to calculate the amount to be infused in a given
length of time; set the infusion rate; and monitor the apparatus frequently (at least every 1 to 2
hours) to make certain that the desired rate is maintained, the integrity of the system remains
intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the
infusion does not stop. A minidropper (60 drops/ml) is the recommended IV tubing in
pediatrics. The IV site should be protected. This may require soft restraints on the child.
Insertion sites do not need to be changed every 24 hours unless a problem is found with the
site. This exposes the child to significant trauma.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
16. It is important to make certain that sensory connectors and oximeters are compatible. Which
can incompatible wiring cause?
a. Hyperthermia
b. Electrocution
c. Pressure necrosis
d. Burns under sensors
ANS: D
It is important to make certain that sensor connectors and oximeters are compatible. Wiring
that is incompatible can generate considerable heat at the tip of the sensor, causing secondand third-degree burns under the sensor. Incompatibility would cause a local irritation or burn.
A low voltage is used, which should not present risk of electrocution. Pressure necrosis can
occur from the sensor being attached too tightly, but this is not a problem of incompatibility.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. The nurse must suction a child with a tracheostomy. Which is the appropriate technique?
a. Encourage the child to cough to raise the secretions before suctioning.
b. Select a catheter with diameter three-fourths as large as the diameter of the
tracheostomy tube.
c. Ensure each pass of the suction catheter would take no longer than 5 seconds.
d. Allow the child to rest after every five times the suction catheter is passed.
ANS: C
Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be
occluded for too long. If the child is able to cough up secretions, suctioning may not be
indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it
is too large, it might block the child’s airway. The child is allowed to rest for 30 to 60 seconds
after each aspiration to allow oxygen tension to return to normal. Then the process is repeated
until the trachea is clear.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. A child is receiving total parenteral nutrition, and at the end of 8 hours, the nurse notes that
200 ml/8 hr is being infused rather than the ordered amount of 300 ml/8 hr. The nurse would
adjust the infusion to which rate during the next 8 hours?
a. 200 ml
b. 300 ml
c. 350 ml
d. 400 ml
ANS: B
The TPN infusion rate should not be increased or decreased without the practitioner being
informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes
from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. In preparing to give “enemas until clear” to a young child, the nurse would select which
solution?
Tap water
Normal saline
Oil retention
Fleet solution
a.
b.
c.
d.
ANS: B
Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is
not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid
overload. Oil-retention enemas will not achieve the “until clear” result. Fleet enemas are not
advised for children because of the harsh action of the ingredients. The osmotic effects of the
Fleet enema can result in diarrhea, which can lead to metabolic acidosis.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The advantages of the ventrogluteal muscle as an injection site in young children include
which considerations? (Select all that apply.)
Less painful than vastus lateralis
Free of important nerves and vascular structures
Cannot be used when child reaches a weight of 20 pounds
Increased subcutaneous fat, which increases drug absorption
Easily identified by well defined landmarks
a.
b.
c.
d.
e.
ANS: B, E
The advantages of the ventrogluteal are being less painful, free of important nerves and
vascular lateralis, and easily identified by major landmarks. The major disadvantage is lack of
familiarity by health professionals and controversy over whether the site can be used before
weight bearing. The use of the ventrogluteal has not been clarified. It has been used in infants,
but clinical guidelines address the need for the child to be walking, thus generally being over
20 pounds. The site has less subcutaneous tissue, which facilitates intramuscular (rather than
subcutaneous) deposition of the drug.
DIF: Cognitive Level: Understand
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 would the nurse give to
the unlicensed assistive personnel caring for this child? (Select all that apply.)
Wear gloves when entering the room.
Wear an isolation gown when entering the room.
Place the child in a special air handling and ventilation room.
A mask should be worn only when holding the child.
Wash your hands upon exiting the room.
a.
b.
c.
d.
e.
ANS: A, E
Droplet transmission involves contact of the conjunctivae or the mucous membranes of the
nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing
microorganisms generated from a person who has a clinical disease or who is a carrier of the
microorganism. Droplets are generated from the source person primarily during coughing,
sneezing, or talking and during procedures such as suctioning and bronchoscopy. Gloves,
gowns, and a mask should be worn when entering the room. Hand washing when exiting the
room should be done with any patient. Because droplets do not remain suspended in the air,
special air handling and ventilation are not required to prevent droplet transmission.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
COMPLETION
1. A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin).
The dosage is 0.07 mg/kg/day, and the child’s weight is 7.2 kg. The physician prescribes the
digoxin to be given once a day by mouth. Each dose will be _____ milligrams. (Record your
answer below using one decimal place.)
ANS:
0.5
Calculate the dosage by weight: 0.07 mg/day  7.2 kg = 0.5 mg/day.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
2. A physician’s prescription reads, “ampicillin sodium 125 mg IV every 6 hours.” The
medication label reads, “1 g = 7.4 ml.” A nurse prepares to draw up _____ milliliters to
administer one dose. (Round your answer to two decimal places.)
ANS:
0.93
Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000
or move the decimal point three places to the right.
1 g = 1000 mg
Formula:
Desired Volume = 125 mg/1000 mg  7.4 ml = 0.925 round to 0.93 ml.
Available
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
3. An infant is on strict intake and output and wears a diaper with a dry weight of 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. Which is the total milliliter output for the shift? _____ (Record your answer as
a whole number below.)
ANS:
73
1 g of wet diaper weight = 1 ml of urine.
The dry weight of the diaper is 24 g.
56 g – 24 g = 32 ml.
65 g – 24 g = 41 ml.
32 ml + 24 ml = 73 ml total output for the shift.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
OTHER
1. The nurse is preparing to insert a nasogastric tube into a 4-year-old child for intermittent
suctioning after abdominal surgery. Place in correct sequence the steps for inserting a
nasogastric tube. Provide the answer using lowercase letters separated by commas (e.g., a, b,
c, d, e, f).
a. Lubricate the nasogastric tube with water-soluble lubricant.
b. Tape the nasogastric tube securely to the child’s face.
c. Check the placement of the tube by aspirating stomach contents.
d. Place the child in the supine position with head slightly hyperflexed.
e. Insert the nasogastric tube through the nares.
f. Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid
process and the umbilicus.
ANS:
D, F, A, E, C, B
The procedure begins by positioning the child in the best position for insertion. Proper
placement of the tube is essential, and incorrectly placed tubes can result in significant harm
to the patient. Correct determination of the length of the tube is a crucial step in the placement
procedure. A convenient and reliable morphologic measurement, the nose-ear–midway to
umbilicus (NEMU) span, approached the accuracy of the age-specific prediction equations
and is easy to use in a clinical setting. Lubrication will assist the ease of tube insertion.
Research supports radiographs as the gold standard for confirmation of enteral tube
placement. Additional methods to check placement, all of which can be done at the bedside,
include visual confirmation of aspirate and pH testing of aspirate. Although auscultation is
still widely used, multiple sources have documented that it is not an accurate method to
confirm enteral tube placement. Securing the tube is an important step to keep the tube in
place.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 21: The Child With Respiratory Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. 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 -hemolytic streptococcal infections.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Decongestant nose drops are prescribed for a 10-month-old infant with an upper respiratory
tract infection. Instructions for nose drops would 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 only when symtomatic.
ANS: A
Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for
more than 3 days to avoid rebound congestion. Drops should be discarded after one illness
because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a
rebound effect after 3 days of use. Drops administered before feedings are more helpful.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
3. When is it generally recommended that a child with acute streptococcal pharyngitis return to
school?
When sore throat has improved.
If no complications develop.
After taking antibiotics for 24 hours.
After taking antibiotics for 3 days.
a.
b.
c.
d.
ANS: C
After children have taken antibiotics for 24 hours, they are no longer contagious to other
children. Sore throat may persist longer than 24 hours after beginning antibiotic therapy, but
the child is no longer considered contagious. Complications may take days to weeks to
develop.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
4. Examining the child’s throat who has epiglottitis by using a tongue depressor might
precipitate which symptom or condition?
Inspiratory stridor
Complete obstruction
Sore throat
Respiratory tract infection
a.
b.
c.
d.
ANS: B
If a child has acute epiglottitis, examination of the throat may cause complete obstruction and
should be performed only when immediate intubation can take place. Stridor is aggravated
when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of
epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which type of croup is always considered a medical emergency?
a. Laryngitis
b. Epiglottitis
c. Spasmodic croup
d. Laryngotracheobronchitis (LTB)
ANS: B
Epiglottitis is always a medical emergency needing antibiotics and airway support for
treatment. Laryngitis is a common viral illness in older children and adolescents, with
hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress
to a medical emergency in some children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. 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. This is most suggestive of
which diagnosis?
a. Bronchitis
b. Bronchiolitis
c. Viral-induced asthma
d. Acute spasmodic laryngitis
ANS: A
Bronchitis is characterized by these symptoms and occurs in children older than 6 years.
Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the
airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children
between 3 months and 3 years of age.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. Which consideration is the most important in managing tuberculosis (TB) in children?
a.
b.
c.
d.
Skin testing annually
Pharmacotherapy
Adequate nutrition
Adequate hydration
ANS: B
Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and
two or three times a week for the remaining 4 months. Pharmacotherapy is the most important
intervention for TB.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
8. The mother of a toddler yells to the nurse, “Help! He is choking to death on his food.” The
nurse determines that lifesaving measures are necessary based on which symptom?
Gagging
Coughing
Pulse over 100 beats/min
Inability to speak
a.
b.
c.
d.
ANS: D
The inability to speak is indicative of a foreign-body airway obstruction of the larynx.
Abdominal thrusts are needed for treatment of the choking child. Gagging indicates irritation
at the back of the throat, not obstruction. Coughing does not indicate a complete airway
obstruction. Tachycardia may be present for many reasons.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated
with sepsis. Which is the priority nursing intervention?
a. Forcing fluids
b. Monitoring pulse oximetry
c. Instituting seizure precautions
d. Encouraging a high-protein diet
ANS: B
Monitoring cardiopulmonary status is an important evaluation tool in the care of the child
with ARDS. Maintenance of vascular volume and hydration is important and should be done
parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a
high-protein diet is not helpful.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. The nurse is caring for a child with possible carbon monoxide poisoning associated with
smoke inhalation. Which treatment is initiated immediately?
a. Administer 100% humidified oxygen.
b. Monitor arterial blood gases.
c. Administer oxygen if respiratory distress develops.
d. The child is rushed to endoscopy for a bronchoscopy.
ANS: A
Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry
is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be normal.
The child should receive 100% oxygen as quickly as possible, not only if respiratory distress
or other symptoms develop.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. In addition to allergens, which other substance or condition has a significant role in the
development and expression of asthma?
a. Medications
b. A viral infection
c. Exposure to cold air
d. A diet high in protein
ANS: B
Viral illnesses cause inflammation that causes increased airway reactivity in asthma.
Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics
may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate
already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with
asthma have no evidence of allergic disease.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. The inflammation associated with asthma contributes to which of the following?
a. Heightened airway reactivity.
b. Decreased resistance in the airway.
c. Allergic hypersensitivity.
d. Increased viscosity of mucous glad secretions.
ANS: A
In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes
constriction, producing impaired respiratory function. In bronchial asthma, there is increased
resistance in the airway. There are multiple causes of asthma, including allergens, irritants,
exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or
development of an immunoglobulin E (IgE)–mediated response is inherited but is not the only
cause of asthma.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. 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 2 agonists
ANS: D
Short-acting 2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is
not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma
exacerbations. Aminophylline is not helpful for acute asthma exacerbation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. Which statement, made by the nurse, expresses accurately the genetic implications associated
with cystic fibrosis?
If it is present in a child, both parents are carriers of this defective gene.
It is inherited as an autosomal dominant trait.
It is a genetic defect found primarily in non-Caucasian population groups.
There is a 50% chance that siblings of an affected child also will be affected.
a.
b.
c.
d.
ANS: A
CF is an autosomal recessive gene inherited from both parents and is inherited as an
autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian
populations. An autosomal recessive inheritance pattern means that there is a 25% chance a
sibling will be infected but a 50% chance a sibling will be a carrier.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. Cystic fibrosis (CF) is suspected in a toddler. Which test aids in establishing this diagnosis?
a. Bronchoscopy
b. Serum calcium
c. Urine creatinine
d. Sweat chloride test
ANS: D
A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy,
although helpful for identifying bacterial infection in children with CF, is not diagnostic.
Serum calcium is normal in children with CF. Urine creatinine is not diagnostic of CF.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. The Heimlich maneuver is recommended for airway obstruction in children older than _____
year(s).
1
4
8
12
a.
b.
c.
d.
ANS: A
The Heimlich maneuver is recommended for airway obstruction in children older than 1 year.
In children younger than 1 year, back blows and chest thrusts are administered. The Heimlich
maneuver can be used in children older than 1 year.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. 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 48 to 72 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: (a)
with other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus,
chronic renal failure, or malnutrition; (b) born or whose parents were born in high-prevalence
(TB) regions of the world; (c) frequently exposed to adults who are HIV infected, homeless,
users of illicit drugs, residents of nursing homes, incarcerated or institutionalized, or migrant
farm workers; and (d) who travel to high-prevalence (TB) regions of the world are positive
when the induration is 10 mm. Children 4 years of age or older without any risk factors are
positive when the induration is 20 mm.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18. Pancreatic enzymes are administered to the child with cystic fibrosis (CF). What nursing
considerations should be included?
Do not administer pancreatic enzymes if the child is receiving antibiotics.
Decrease dose of pancreatic enzymes if the child is having frequent, bulky stools.
Administer pancreatic enzymes between meals if at all possible.
Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of
food taken at the beginning of a meal.
a.
b.
c.
d.
ANS: D
Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal
or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage
of enzymes should be increased if the child is having frequent, bulky stools. Enzymes should
be given just before meals and snacks.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1. Parents have understood teaching about prevention of childhood otitis media if they make
which statement? (Select all that apply.)
a. “We will avoid second hand smoke.”
b. “Breastfeeding will be discontinued after 4 months of age.”
c. “We will place the child flat right after feedings.”
d. “A conjugate vaccine may be administered.”
e. “We will adminster medications as prescribed.”
ANS: A, D, E
Parents have understood the teaching about preventing childhood otitis media if they respond
they will keep childhood immunizations up to date. The child should be maintained upright
during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at
least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child
is in the supine position.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Nursing care of the child with a bacterial pneumonia includes which interventions? (Select all
that apply.)
Cluster care to conserve energy
Round-the-clock administration of antitussive agents
Strict intake and output to avoid congestive heart failure
Administration of antibiotics
Provide adequate hydration
a.
b.
c.
d.
e.
ANS: A, D, E
Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased
pulmonary reserve, and the clustering of care is essential. Antitussive agents are used
sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential
to kept secretions as liquefied as possible.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV)
bronchiolitis. Which intervention would be included in the child’s care? (Select all that apply.)
Ensure contact precautions are implemented.
Administer antibiotics.
Administer cough syrup.
Provide 8 ounces of formula every 4 hours.
Cluster care to encourage adequate rest.
Place on noninvasive oxygen monitoring for oxygen saturation <90%.
a.
b.
c.
d.
e.
f.
ANS: A, 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. Antibiotics do not treat illnesses with viral causes. Cough syrup suppresses
clearing of respiratory secretions and is not indicated for young children.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy. Which action
should the nurse include in the child’s postoperative care plan? (Select all that apply.)
Notify the surgeon if the child swallows frequently.
Apply a heat collar to the child for pain relief.
Place the child on the abdomen until fully awake.
Prepare for oral liquids immediately following procedure.
Encourage the child to cough frequently.
a.
b.
c.
d.
e.
ANS: A, C
Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should
be placed on the abdomen or the side to facilitate drainage. The child can drink diluted juice,
cool water, or popsicles after the procedure. An ice collar should be used after surgery.
Frequent coughing and nose blowing should be avoided.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. A nurse is caring for a school-age child with left unilateral pneumonia, pleural effusion, and a
chest tube connected to closed chest drainage. Which interventions would the nurse
implement when caring for this child? (Select all that apply.)
a. Manual suctioning of the chest tube every shift
b. Assessing the chest tube and drainage device for correct settings
c. Administering prescribed doses of antibiotics
d. Clamping the chest tube when child ambulates
e. Monitoring for need of supplemental oxygen
ANS: B, C, E
Nursing care of the child with a chest tube requires close attention to respiratory status; the
chest tube and drainage device used are monitored for proper function (i.e., drainage is not
impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube
insertion site is intact, water seal is maintained, and chest tube remains in place). Movement in
bed and ambulation with a chest tube are encouraged according to the child’s respiratory
status, but children require frequent doses of analgesia. Supplemental oxygen may be required
in the acute phase of the illness and may be administered by nasal cannula, face mask, flowby, or face tent. The child should be positioned on the left side, not the right. Lying on the
affected side if the pneumonia is unilateral (“good lung up”) splints the chest on that side and
reduces the pleural rubbing that often causes discomfort. The chest tube should never be
clamped; this can cause a pneumothorax. The chest tube should be maintained to the
underwater seal at all times.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
COMPLETION
1. A nurse is interpreting the results of a child’s peak expiratory flow rate. Which percentage,
either at this number or less than this number, is considered to be a red zone? ______ (Record
your answer in a whole number.)
ANS:
49
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 would be administered.
Notify the practitioner if the peak expiratory flow rate does not return immediately and stay in
yellow or green zones.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
OTHER
1. The nurse enters a room and finds a 6-year-old child who is unconscious. After calling for
help and before being able to use an automatic external defibrillator, which steps would the
nurse take? Place in correct order. Provide answer using lowercase letters separated by
commas (e.g., A, B, C, D, E).
a. Place patient on a hard surface.
b. Perform 30 chest compressions at a depth of 2 inches.
c. Assesses pulse and breathing for 5 to 10 seconds, finding neither
d. Place heel of one hand on lower half of sternum with other hand on top.
e. Give two rescue breaths using the bag-mask ventilation.
ANS:
C, A, D, B, E
These steps follow the guidelines for resuscitation from the American Heart Association.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 22: The Child With Gastrointestinal Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which condition in a child would alert a nurse for increased fluid requirements?
a. Fever
b. Mechanical ventilation
c. Congestive heart failure
d. Increased intracranial pressure (ICP)
ANS: A
Fever leads to great insensible fluid loss in young children because of increased body surface
area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be
monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid
overload in children. Increased ICP does not lead to increased fluid requirements in children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The term melena suggests bleeding from which area of the gastrointestinal tract?
a. Perianal or rectal area
b. Hemorrhoids or anal fissures
c. Upper gastrointestinal (GI) tract
d. Lower GI tract
ANS: C
Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood
from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. Which type of dehydration is defined as “dehydration that occurs in conditions in which
electrolyte and water deficits are present in approximately balanced proportion”?
Isotonic
Hypotonic
Hypertonic
All types
a.
b.
c.
d.
ANS: A
Isotonic dehydration is the correct term for this definition and is the most frequent form of
dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds
the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss
in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a
larger intake of electrolytes. This definition is specific to isotonic dehydration.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. An infant is brought to the emergency department with dehydration. Which physical
assessment finding does the nurse expect?
Puffy appearance
Bradycardia
Poor skin turgor
Brisk capillary refill
a.
b.
c.
d.
ANS: C
Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and
tachycardia. The infant would have prolonged capillary refill, not brisk.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which pathogen is the most common cause of diarrhea-associated hospitalization in children?
a. Norovirus
b. Shigella organisms
c. Rotavirus
d. Salmonella organisms
ANS: C
Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia
(parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial
pathogen that is uncommon in the United States.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen
confirm this diagnosis?
Eosinophils
Occult blood
pH less than 6
Neutrophils
a.
b.
c.
d.
ANS: D
Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance
and parasitic infections are suspected in the presence of eosinophils. Occult blood may
indicate pathogens such as Shigella, Campylobacter, or hemorrhagic Escherichia coli strains.
A pH of less than 6 may indicate carbohydrate malabsorption or secondary lactase
insufficiency.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. 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 the aganglionic colon
ANS: D
Most children with Hirschsprung disease require surgical rather than medical management.
Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and
restore normal bowel motility and function of the internal anal sphincter. Preoperative
management may include enemas and low-fiber, high-calorie, high-protein diet, until the child
is physically ready for surgery. The colostomy that is created in Hirschsprung disease is
usually temporary.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which clinical manifestation would be suggestive of acute appendicitis?
a. Left upper quadrant pain
b. Bright red or dark red rectal bleeding
c. Abdominal pain that is relieved by eating
d. Abdominal pain that is most intense at McBurney point
ANS: D
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes
to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and
is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain
that is relieved by eating are not signs of acute appendicitis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. When caring for a child with probable appendicitis, the nurse would 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. 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. Bright red rectal bleeding.
d. Medical interventions are usually sufficient to treat the problem.
ANS: C
Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to
profuse intestinal bleeding. It is twice as common in males as in females, and complications
are more frequent in males. Meckel diverticulum is the most common congenital
malformation of the GI tract and is present in 1% to 4% of the general population. The
standard therapy is surgical removal of the diverticulum.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. A nurse is admitting a child with Crohn disease and the parents ask the nurse, “How is this
disease different from ulcerative colitis?” Which statement would the nurse make when
answering this question?
a. “With Crohn disease the inflammatory process can involve any part of the GI
tract.”
b. “There is no difference between the two diseases.”
c. “The inflammation with Crohn disease is limited to the colon and rectum.”
d. “Ulcerative colitis is characterized by skip lesions.”
ANS: A
The chronic inflammatory process of Crohn disease involves any part of the GI tract from the
mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers
of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa,
there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative
colitis is limited to the colon and rectum, with the distal colon and rectum the most severely
affected. Inflammation affects the mucosa and submucosa and involves continuous segments
along the length of the bowel with varying degrees of ulceration, bleeding, and edema.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which is used to treat moderate to severe inflammatory bowel disease?
a. Antacids
b. Antibiotics
c. Corticosteroids
d. Antidiarrheal medications
ANS: C
Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the
inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal medications
are not drugs of choice in the treatment of inflammatory bowel disease. Antibiotics may be
used as an adjunctive therapy to treat complications.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. Why are bismuth subsalicylate, clarithromycin, and metronidazole prescribed for a child with
a peptic ulcer?
Eradicate Helicobacter pylori
Coat gastric mucosa
Treat epigastric pain
Reduce gastric acid production
a.
b.
c.
d.
ANS: A
The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is
effective in the treatment of H. pylori and is prescribed to eradicate it.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. Which is a clinical manifestation of pyloric stenosis?
a. Abdominal rigidity
b. Substernal retraction
c. Palpable olive-like mass
d. Marked distention of lower abdomen
ANS: C
Visible gastric peristaltic waves that move from left to right across the epigastrium and weight
loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded
abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower
abdomen, is distended.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. Which describes an invagination of one segment of bowel within another?
a. Atresia
b. Stenosis
c. Herniation
d. Intussusception
ANS: D
Intussusception occurs when a proximal section of the bowel telescopes into a more distal
segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in
lymphatic and venous obstruction. Invagination of one segment of bowel within another is the
definition of intussusception, not atresia, stenosis, or herniation.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-
guided pneumoenema 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. Plan to move forward with procedure.
ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is
immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic
care plan. The first action would be to report the normal stool to the practitioner.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. Which is an important nursing consideration in the care of a child with celiac disease?
a. Refer to a nutritionist for detailed dietary instructions and education.
b. Help child and family understand that diet restrictions are usually only temporary.
c. Teach proper hand washing and standard precautions to prevent disease
transmission.
d. Suggest ways to cope more effectively with stress to minimize symptoms.
ANS: A
The main consideration is helping the child adhere to dietary management. Considerable time
is spent explaining to the child and parents about the disease process, the specific role of
gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist
would help in this process. The most severe symptoms usually occur in early childhood and
adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible
or stress related.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
18. An infant with short bowel syndrome will be discharged home on total parenteral nutrition
(TPN) and gastrostomy feedings. Which would be included in the discharge teaching?
Prepare family for impending death.
Teach family signs of central venous catheter infection.
Teach family how to calculate caloric needs.
Secure TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.
a.
b.
c.
d.
ANS: B
During TPN therapy, care must be taken to minimize the risk of complications related to the
central venous access device, such as catheter infections, occlusions, or accidental removal.
This is an important part of family teaching. The prognosis for patients with short bowel
syndrome depends in part on the length of residual small intestine. It has improved with
advances in TPN. Although parents need to be taught about nutritional needs, the caloric
needs and prescribed TPN and rate are the responsibility of the health care team. The tubes
should not be placed under the diaper due to risk of infection.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. Parents of a child undergoing an endoscopy to rule out peptic ulcer disease (PUD) from H.
pylori ask the nurse, “If H. pylori is found, will my child need another endoscopy to know that
it is gone?” Which is the nurse’s best response?
a. “Yes, the only way to know the H. pylori has been eradicated is with another
endoscopy.”
b. “We can collect a stool sample and confirm that the H. pylori has been eradicated.”
c. “A blood test can be done to determine that the H. pylori is no longer present.”
d. “Your child will always test positive for H. pylori because after treatment it goes
into remission but can’t be completely eradicated.”
ANS: B
An upper endoscopy is the procedure initially performed to diagnose PUD. A biopsy can
determine the presence of H. pylori. Polyclonal and monoclonal stool antigen tests are an
accurate, noninvasive method to confirm H. pylori has been eradicated after treatment. A
blood test can identify the presence of the antigen to this organism, but because H. pylori was
already present, it would not be as accurate as a stool sample to determine whether it has been
eradicated. H. pylori can be treated and, once the treatment is complete, the stool sample can
determine that it was eradicated.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20. A child has recurrent abdominal pain (RAP) and a dairy-free diet has been prescribed for 2
weeks to rule out which disease or condition?
Lactose intolerance
Celiac disease
Sensitivity to high sugar content
Peptic ulcer disease
a.
b.
c.
d.
ANS: A
Treatment for RAP involves providing reassurance and reducing or eliminating symptoms.
Dietary modifications may include removal of dairy products to rule out lactose intolerance.
Fructose is eliminated to rule out sensitivity to high sugar content, and gluten is removed to
rule out celiac disease. A dairy-free diet would not rule out peptic ulcer disease.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. A nurse is admitting an infant with biliary atresia. Which are clinical manifestation are typical
in biliary atresia? (Select all that apply.)
Jaundice
Vomiting
Hepatomegaly
Absence of stooling
Dark urine
a.
b.
c.
d.
e.
ANS: A, C, E
Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in
the sclera and may be present at birth but is usually not apparent until age 2 to 3 weeks.
Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are
common but occur later. Stools are large and lighter in color than expected because of the lack
of bile.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which is correct 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 infection can be transferred to an infant of a breastfeeding mother.
d. Principal mode of transmission for hepatitis B is fecal-oral route.
e. The average incubation period is 120 days.
ANS: B, E
The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is
protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding
mother, especially if the mother’s nipples are cracked. The onset of hepatitis B is insidious.
Immunity develops after one exposure to hepatitis B. Hepatitis B has a carrier state. The fecaloral route is the principal mode of transmission for hepatitis A. Hepatitis B is transmitted
through the parenteral route.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A neonatal nurse is planning care for a newborn with known tracheoesophageal fistula (TEF).
Which interventions would the nurse plan to implement? (Select all that apply.)
Positioning with head elevated.
Implement feedings after radiographs
Nasogastric tube insertion with continuous low wall suction
Initiate IV fluids
Antibiotic therapy if there is a concern of aspiration
a.
b.
c.
d.
e.
ANS: A, C, D, E
The most desirable position for a newborn who has TEF is supine (or sometimes prone) with
the head elevated on an inclined plane of at least 30 degrees. This positioning minimizes the
reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially
when intra-abdominal pressure is elevated. It is imperative to immediately remove any
secretions that can be aspirated. Until surgery, the blind pouch is kept empty by intermittent or
continuous suction through an indwelling double-lumen or Replogle catheter passed orally or
nasally to the end of the pouch. In some cases, a percutaneous gastrostomy tube is inserted
and left open so that any air entering the stomach through the fistula can escape, thus
minimizing the danger of gastric contents being regurgitated into the trachea. The gastrostomy
tube is emptied by gravity drainage. Feedings through the gastrostomy tube and irrigations
with fluid are contraindicated before surgery in an infant with a distal TEF. A nasogastric tube
to low intermittent suctioning could not be accomplished because the esophagus ends in a
blind pouch in TEF.
DIF: Cognitive Level: Apply
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 would the nurse anticipate implementing? (Select all that apply.)
NPO for 24 hours
Administration of analgesics for pain
Ice bag to the incisional area
IV fluids continued until tolerating PO
Clear liquids as the first feeding
a.
b.
c.
d.
e.
ANS: B, D, E
Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear
liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until
the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should
be given around the clock because pain is continuous. Ice should not be applied to the
incisional area as it vasoconstricts and would reduce circulation to the incisional area and
impair healing.
DIF: Cognitive Level: Apply
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 school-age child
with constipation. Which would the nurse suggest be implemented in the diet? (Select all that
apply.)
a. White rice
b. Popcorn
c. Beans
d. Bran pancakes
e. Raw carrots
ANS: B, C, D, E
High-fiber foods include popcorn, beans, bran pancakes, and raw carrots. Unrefined (brown)
rice is high in fiber, but white rice is not. Raw fruits, especially those with skins or seeds,
other than ripe banana or avocado, are high in fiber.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
Chapter 23: The Child With Cardiovascular Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse is caring for a school-age child who has had a cardiac catheterization, and upon
assessment of the leg finds the bandage and bed soaked with blood. Which is the priority
nursing action?
a. Notify physician
b. Apply new bandage with more pressure
c. Place the child in Trendelenburg position
d. Apply direct pressure above catheterization site
ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and
applying a new bandage can be done after pressure is applied. The nurse can have someone
else notify the physician while the pressure is being maintained. It is not a helpful intervention
to place the girl in the Trendelenburg position. It would increase the drainage from the lower
extremities.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which is the expected outcome from surgical closure of the ductus arteriosus?
a. Stops the loss of unoxygenated blood to the systemic circulation
b. Decreases the edema in legs and feet
c. Increases the oxygenation of blood
d. Prevents the return of oxygenated blood to the lungs
ANS: D
The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lowerpressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no
additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary
artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher
pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary
circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not
directly affect the edema. Increasing the oxygenation of blood would not interfere with the
return of oxygenated blood to the lungs.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left
atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the
pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles.
Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries
results in mixed blood flow.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is conducting a staff in-service on congenital heart defects. Which structural defect
constitutes tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect,
overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial
stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy,
is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left
ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure
(HF). Which is a beneficial effect of administering digoxin (Lanoxin)?
It decreases edema.
It decreases cardiac output.
It increases heart size.
It increases venous pressure.
a.
b.
c.
d.
ANS: A
Digoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous
pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size
and venous pressure are decreased by digoxin.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
6. A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which
drug would the nurse administer?
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.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
7. A 6-month-old infant is receiving digoxin (Lanoxin). The nurse would notify the practitioner
and withhold the medication if the apical pulse is less than _______ beats/min.
60
70
90 to 110
110 to 120
a.
b.
c.
d.
ANS: C
If a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld;
60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110
beats/min is the determination for not giving a digoxin dose to infants and young children.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
8. The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common
sign of digoxin toxicity?
Seizures
Vomiting
Bradypnea
Tachycardia
a.
b.
c.
d.
ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin
toxicity. The child will have a slower heart rate, not respiratory rate. The heart rate will be
slower, not faster.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
9. The nurse encourages the family to give a child who is prescribed furosemide (Lasix) foods
such as bananas, oranges, and leafy vegetables because they are high in which nutrient?
Chlorides
Potassium
Sodium
Vitamins
a.
b.
c.
d.
ANS: B
Diuretics that work on the proximal and distal renal tubules contribute to increased losses of
potassium. The child’s diet should be supplemented with this electrolyte. With this type of
diuretic, potassium must be monitored and supplemented as needed.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
10. Which is important to decrease the risk of a cerebrovascular accident in a patient with
hypoxemia secondary to a cardiac defect?
Minimize seizures
Prevent dehydration
Promote cardiac output
Reduce energy expenditure
a.
b.
c.
d.
ANS: B
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in
hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting
cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular
accidents.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with
other children because of possible overexertion. The nurse’s reply would be based on which
statement?
a. The child needs opportunities to play with peers.
b. The child needs to understand that peers’ activities are too strenuous.
c. Parents can meet all of the child’s needs.
d. Constant parental supervision is needed to avoid overexertion.
ANS: A
The child needs opportunities for social development. Children usually limit their activities if
allowed to set their own pace. The child will limit activities as necessary. Parents must be
encouraged to seek appropriate social activities for the child, especially before kindergarten.
The child needs to have activities that foster independence. The child will be able to regulate
activities.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity
12. Which is an important nursing consideration when suctioning a child who is intubated after
cardiac surgery with cardiopulmonary bypass?
Perform suctioning at least every hour.
Suction for no longer than 30 seconds at a time.
Administer supplemental oxygen before and after suctioning.
Expect symptoms of respiratory distress when suctioning.
a.
b.
c.
d.
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.
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13. The nurse is caring for a child after heart surgery. Which would the nurse do if evidence of
cardiac tamponade is found?
Increase analgesia
Apply warming blankets
Immediately report this to physician
Encourage child to cough, turn, and breathe deeply
a.
b.
c.
d.
ANS: C
If evidence is noted of cardiac tamponade, which is blood or fluid in the pericardial space
constricting the heart, the physician is notified immediately of this life-threatening
complication. Increasing analgesia may be done before the physician drains the fluid, but the
physician must be notified. Warming blankets are not indicated at this time. Encouraging the
child to cough, turn, and breathe deeply should be deferred till after the evaluation by the
physician.
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14. Which is an important nursing consideration when chest tubes will be removed from a young
child?
Explain that it is not painful.
Prepare a Band-Aid for the dressing.
Administer analgesics before the procedure.
Expect bright red drainage for several hours after removal.
a.
b.
c.
d.
ANS: C
It is appropriate to prepare the child for the removal of chest tubes with analgesics. Shortacting medications can be used that are administered through an existing IV line. A sharp,
momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, airtight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should
be found on removal.
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TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
15. 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.
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16. Which is a serious complication which occurs in more than half of the cases of rheumatic
fever?
a. Seizures
b. Cardiac arrhythmias
c. Pulmonary hypertension
d. Cardiac valve damage
ANS: D
Cardiac valve damage is the most significant complication of rheumatic fever. Seizures,
cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic
fever.
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TOP: Integrated Process: Nursing Process: Assessment
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17. The nurse is admitting a child with rheumatic fever. Which therapeutic management would the
nurse expect to implement?
a. Administering penicillin
b. Ambulation as tolerated
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.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
18. When caring for the child with Kawasaki disease, the nurse would know which information?
a. A child’s fever is usually responsive to antibiotics within 48 hours.
b. The principal area of involvement is the joints.
c. The child is very docile through the illness.
d. Therapeutic management includes administration of gamma globulin and
salicylates (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.
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19. Which occurs in early 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.
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MULTIPLE RESPONSE
1. Which are organisms are known to cause bacterial endocarditis? (Select all that apply.)
a. Staphylococcus aureus
b. Streptococcus hemolyticus
c. Staphylococcus albicans
d. Viridans streptococci
e. Candida albicans
ANS: A, D, E
Viridans streptococci and Staphylococcus aureus are the most common causative agent in
bacterial (infective) endocarditis. Other causative agents include gram-negative bacteria and
fungi such as Candida albicans, Streptococcus hemolyticus, and Staphylococcus albicans are
not common causative agents.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Nursing interventions for the child following a venous cardiac catheterization would include
which actions? (Select all that apply.)
a. Allow ambulation as tolerated.
b. Monitor vital signs as frequently as every 15 minutes.
c. Assess the affected extremity for temperature and color.
d. Check pulses below the catheterization site for equality and symmetry.
e. Remove pressure dressing after 4 hours.
f. Keep affected extremity straight for 10 to 12 hours.
ANS: B, C, D
The extremity that was used for access for the cardiac catheterization must be checked for
temperature and color. Coolness and blanching may indicate arterial occlusion. The child
should have a patent peripheral intravenous line (PIV) to ensure adequate hydration. The child
should remain on bed rest with the leg extended for a minimum of 4 hours. Initially vital signs
are taken every 15 minutes, with emphasis on a heart rate counted for 1 minute. Pulses above
the catheterization site should not be affected by the catheterization. Pulses distal to the site
should be monitored. The pressure dressings should not be removed for 24 hours.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. Which clinical manifestation would the nurse expect to see as shock progresses in a child and
becomes decompensated shock? (Select all that apply.)
High blood pressure
Irritability
Cool extremities
Confusion
Narrowing pulse pressure
Tachypnea
a.
b.
c.
d.
e.
f.
ANS: C, D, E, F
Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary
refill time are beginning signs of decompensated shock. Thirst, diminished urinary output,
irritability, apprehension, normal blood pressure, and narrowing pulse pressure are signs of
compensated shock.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is conducting discharge teaching about signs and symptoms of heart failure to
parents of an infant with cardiomyopathy. Which signs and symptoms would the nurse
include? (Select all that apply.)
a. Warm flushed extremities
b. Poor feeding
c. Rapid weight gain
d. Tachypnea
e. Abnormally slow pulse rate
ANS: B, C, D
Poor feeding, rapid weight gain, and tachypnea are all important signs of heart failure. Further
the extremities are cool due to ineffective peripheral circulation, and the pulse rate is high.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
OTHER
1. Which interventions would the nurse implement for an infant experiencing a hypercyanotic
spell? Place in order from the highest-priority intervention to the lowest-priority intervention.
Provide the answer using lowercase letters separated by commas (e.g., A, B, C, D).
a. Administer 100% oxygen by blow-by.
b. Place the infant in knee-chest position.
c. Begin volume expansion if needed.
d. Give morphine subcutaneously or by an existing intravenous line.
ANS:
B, A, D, C
Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen in
infants with tetralogy of Fallot, may occur in any child whose heart defect includes
obstruction to pulmonary blood flow and communication between the ventricles. The infant
becomes acutely cyanotic and hyperpneic because sudden infundibular spasm decreases
pulmonary blood flow and increases right-to-left shunting. Because profound hypoxemia
causes cerebral hypoxia, hypercyanotic spells require prompt assessment and treatment to
prevent brain damage or possibly death. The infant would first be placed in the knee-chest
position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate the
hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, begin volume
expansion if needed.
Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen in
infants with tetralogy of Fallot, may occur in any child whose heart defect includes
obstruction to pulmonary blood flow and communication between the ventricles. The infant
becomes acutely cyanotic and hyperpneic because sudden infundibular spasm decreases
pulmonary blood flow and increases right-to-left shunting. Because profound hypoxemia
causes cerebral hypoxia, hypercyanotic spells require prompt assessment and treatment to
prevent brain damage or possibly death. The infant should first be placed in the knee-chest
position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate the
hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, the nurse
should remain calm.
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TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. An inpatient child with IV access is experiencing an anaphylactic reaction to a snack brought
by a friend containing peanut products. Prioritize the actions that follow: Place in correct
sequence. Provide the answer using lowercase letters separated by commas (e.g., A, B, C, D).
a. Administer IV epinephrine.
b. Administer fluids to restore blood volume.
c. Establish an airway.
d. Monitor child for biphasic reaction.
ANS:
C, A, B, D
The correct sequence of actions is to establish an airway, administer epinephrine, Administer
fluids to restore blood volume, and monitor child for biphasic reaction.
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TOP: Integrated Process: Nursing Process: Implementation
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Chapter 24: The Child With Hematologic or Immunologic Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A child who needs several blood tests is crying and upset because of memories of the
venipuncture done at the clinic 2 days ago. What would the nurse explain?
The venipuncture discomfort is very brief.
Only one venipuncture will be needed.
A topical application of local anesthetic can used to numb the area.
Most blood tests on children require only a finger puncture because a small amount
of blood is needed.
a.
b.
c.
d.
ANS: C
Preschool children are concerned with both pain and the loss of blood. When preparing the
child for venipuncture, the nurse will use a topical anesthetic to eliminate any pain. This is a
traumatic experience for preschool children. They are concerned about their bodily integrity. A
local anesthetic should be used, and a bandage should be applied to maintain bodily integrity.
The nurse should not promise one attempt in case multiple attempts are required. Both finger
punctures and venipunctures are traumatic for children. Both require preparation.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. 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 infant’s emaciated appearance.
c. Preterm infants are particularly at risk.
d. Clinical manifestations result from a decreased intake of milk and the preterm
addition of solid foods.
ANS: C
Iron is transferred from the mother to the fetus during the last trimester of pregnancy.
Maternally derived iron stores are usually adequate for the first 5-6 months in a full-term
infant, but only 2-3 months in preterm infants. In iron-deficiency anemia, the child’s clinical
appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic
system is not depressed in iron-deficiency anemia. The bone marrow produces red cells that
are smaller and contain less hemoglobin than normal red cells. Children who are iron deficient
from drinking excessive quantities of milk are usually pale and overweight. They are
receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations
result from decreased intake of iron-fortified solid foods and an excessive intake of milk.
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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which would 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. Give iron with milk or milk substances.
c. Adequate dosage will turn the stools a tarry green color.
d. Do not administer iron through a straw.
ANS: C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the iron
dose is adequate, the stools will become a tarry green color. The lack of the color change may
indicate insufficient iron. The iron should be given in two divided doses between meals when
the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic
environment. Vomiting and diarrhea may occur with iron administration. If these occur, the
iron should be given with meals, and the dosage reduced, then gradually increased as the child
develops tolerance. Liquid preparations of iron stain the teeth. They should be administered
through a straw and the mouth rinsed after administration.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
4. When both parents have sickle cell trait, which is the chance their children will have sickle
cell anemia?
25%
50%
75%
100%
a.
b.
c.
d.
ANS: A
Sickle cell anemia is inherited in an autosomal recessive pattern. If both parents have sickle
cell trait (one copy of the sickle cell gene), then for each pregnancy, a 25% chance exists that
their child will be affected with sickle cell disease. With each pregnancy, a 50% chance exists
that the child will have sickle cell trait. Percentages of 75% and 100% are too high for the
children of parents who have sickle cell trait.
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TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. Which clinical manifestation would the nurse expect when a child with sickle cell anemia
experiences an acute vasoocclusive crisis?
a. Hepatomegaly
b. Cardiomegaly
c. Circulatory collapse
d. Painful swelling of hands and feet
ANS: D
A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the
extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain
resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances
occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs,
hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive phenomena.
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6. Why is meperidine (Demerol) not recommended for children in sickle cell crisis?
a. May induce seizures
b. Is easily addictive
c. Not adequate for pain relief
d. Given by intramuscular injection
ANS: A
A metabolite of meperidine, normeperidine, is a central nervous system stimulant that
produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with
repetitive dosing. Patients with sickle cell disease are particularly at risk for normeperidineinduced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is
adequate for pain relief. It is available for IV infusion.
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7. What is the purpose of chelation therapy in the treatment of beta-thalassemia?
a. Treats the disease
b. Eliminates excess iron
c. Decreases risk of hypoxia
d. Manages 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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8. 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 marrow–failure condition in which the formed elements of
the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which
normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin.
Thalassemia major is a group of blood disorders characterized by deficiency in the production
rate of specific hemoglobin globin chains. Iron-deficiency anemia results in a decreased
amount of circulating red cells.
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9. Parents of a hemophiliac child ask the nurse, “Can you describe hemophilia to us?” Which
response by the nurse is descriptive of most cases of hemophilia?
a. Autosomal dominant disorder causing deficiency in a factor involved in the blood-
clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged
bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become moonshaped
ANS: C
The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The
two most common forms of the disorder are factor VIII deficiency, hemophilia A or classic
hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. The inheritance
pattern is X-linked recessive. The disorder involves coagulation factors, not platelets, and
does not involve red cells or the Y chromosomes.
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10. Which describes the pathology of immune thrombocytopenia?
a. Bone marrow failure in which all elements are suppressed
b. Deficiency in the production rate of globin chains
c. Diffuse fibrin deposition in the microvasculature
d. An excessive destruction of platelets
ANS: D
ITP involves the evolution of antibodies against multiple platelet antigens and cytotoxic T
cells that cause platelet destruction in blood and spleen and/or inhibition of platelet production
in the bone marrow. Bone marrow failure is associated with aplastic anemia. Deficient
production of globin chains is associated with Thalassemia. Diffuse fibrin deposition in the
microvascular is associated with disseminated intravascular coagulation.
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11. Which is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+
T cells?
Wiskott-Aldrich syndrome
Idiopathic thrombocytopenic purpura
Acquired immunodeficiency syndrome (AIDS)
Severe combined immunodeficiency disease
a.
b.
c.
d.
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.
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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. The nurse is planning care for an adolescent with HIV. Which is the priority nursing goal?
a. Preventing infection
b. Preventing secondary cancers
c. Restoring immunologic defenses
d. Identifying source of infection
ANS: A
The HIV virus primarily infects a specific subset of T lymphocytes, the CD4+ T cells, but it
can also invade cells of the monocyte-macrophage lineage. The virus takes over the
machinery of the CD4+ lymphocyte, using it to replicate itself, rendering the CD4+ cell
dysfunctional. The CD4+ lymphocyte count gradually decreases over time; at some point,
physical symptoms appear. The count eventually reaches a critical level at which there is
substantial risk of opportunistic illnesses, followed by risk of death. Preventing and treating
opportunistic infection becomes a primary nursing goal.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
13. Which statement describes severe combined immunodeficiency syndrome (SCIDS)?
a. Absence of both humoral and cellular immunity.
b. Production of red blood cells is affected.
c. Adult hemoglobin is replaced by abnormal hemoglobin.
d. There is a deficiency of T and B lymphocyte production.
ANS: A
Severe combined immunodeficiency syndrome (SCIDS) is a genetic disorder that results in
deficits of both humoral and cellular immunity. Wiskott-Aldrich is an X-linked recessive
disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary
disorder of red cell production. Sickle cell disease is characterized by the replacement of adult
hemoglobin with an abnormal hemoglobin S.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. Which is an immediate sign or symptom of an air embolus which can be a complication of
blood transfusions?
Chills and shaking
Nausea and vomiting
Irregular heart rate
Sudden difficulty in breathing
a.
b.
c.
d.
ANS: D
An air embolus can occur when blood is transfused under pressure. The nurse should
normalize pressure before the bag is empty when infusing under pressure and clear tubing of
air in the tubing. Chills and irregular heart rate can be associated with hypothermia, nausea
can be due to electrolyte imbalances.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
15. 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
which is most suggestive of
a. ir emboli.
b. allergic reaction.
c. hemolytic reaction.
d. circulatory overload.
ANS: D
Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and
apprehension. Air emboli should be avoided by carefully flushing all tubing of air before
connecting to patient. Chills, shaking, nausea, and vomiting are associated with hemolytic
reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. Which statement made by a nursing student indicates a correct understanding of the
information about first aid?
a. “If a child loses a tooth due to injury, I would place the tooth in warm milk.”
b. “If a child has recurrent abdominal pain, I would 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 would irrigate the eye with normal
saline.”
d. “If a child has a nosebleed, I would have the child sit up and lean forward.”
ANS: D
If a child has a nosebleed, the child should lean forward, not lie down. A tooth should be
placed in cold milk or saliva for transporting to a dentist. Recurrent abdominal pain is a
physiologic problem and requires further evaluation. If a chemical burn occurs in the eye, the
eye should be irrigated with water for 20 minutes.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. Which interventions would the nurse plan to implement for a child admitted with hemophilia?
(Select all that apply.)
Finger sticks for blood work instead of venipunctures
Avoidance of IM injections
Acetaminophen (Tylenol) for mild pain control
Soft tooth brush for dental hygiene
Administration of packed red blood cells
a.
b.
c.
d.
e.
ANS: B, C, D
Nurses should take special precautions when caring for a child with hemophilia to prevent the
use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is
substituted for IM injections whenever possible. Venipunctures for blood samples are usually
preferred for these children. There is usually less bleeding after the venipuncture than after
finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be used.
Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft
toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red
blood cells are not administered. The primary therapy for hemophilia is replacement of the
missing clotting factor. The products available are factor VIII concentrates.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which would the nurse teach about prevention of sickle cell crises to parents of a preschool
child with sickle cell disease? (Select all that apply.)
Limit fluids at bedtime.
Notify the health care provider if a fever of 38.5 C (101.3 F) or greater occurs.
Give penicillin as prescribed.
Use ice packs to decrease the discomfort of vasoocclusive pain in the legs.
Signs and symptoms of respiratory problems.
a.
b.
c.
d.
e.
ANS: B, C, E
The most important issues to teach the family of a child with sickle cell anemia are to (1) seek
early intervention for problems, such as a fever of 38.5 C (101.3 F) or greater; (2) give
penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as
respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse
emphasizes the importance of adequate hydration to prevent sickling and to delay the
adhesion–stasis–thrombosis–ischemia cycle. It is not sufficient to advise parents to “force
fluids” or “encourage drinking.” They need specific instructions on how many daily glasses or
bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored
ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired
kidney function result in the problem of enuresis. Parents who are unaware of this fact
frequently use the usual measures to discourage bedwetting, such as limiting fluids at night.
Enuresis is treated as a complication of the disease, such as joint pain or some other symptom,
to alleviate parental pressure on the child. Ice should not be used during a vasoocclusive pain
crisis because it vasoconstricts and impairs circulation even more.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The pathophysiology of disseminated intravascular coagulation include which of the
following clinical manifestations? (Select all that apply.)
Obstruction of blood flow with tissue necrosis
Local and widespread fibrin deposition
Rapid conversion of fibrinogen to fibrin
Blockage of the microcirculation causing vasoocclusion
Conversion of red bone marrow to yellow, fatty bone marrow
a.
b.
c.
d.
e.
ANS: A, B, C
DIC occurs when the first stage of the coagulation process is abnormally stimulated. Although
no well-defined sequence of events occurs, two distinct phases can be identified. First, when
the clotting mechanism is triggered in the circulation, thrombin is generated in greater
amounts than can be neutralized by the body. Consequently, there is rapid conversion of
fibrinogen to fibrin, with aggregation and destruction of platelets. Local and widespread fibrin
deposition occurs in blood vessels, which causes obstruction of blood flow with eventual
necrosis of tissues. Conversion of red bone marrow to yellow occurs in Thalassemia.
Blockage of the microcirculation causing vasoocclusion is associated with Sickle Cell anemia.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
OTHER
1. A preschool child begins to exhibit signs of a transfusion reaction. Place in order the
interventions the nurse would implement sequencing from the highest priority to the lowest.
Provide the answer using lowercase letters separated by commas (e.g., A, B, C, D).
a. Take the vital signs.
b. Stop the transfusion.
c. Notify the practitioner.
d. Maintain a patent IV line with normal saline.
ANS:
B, A, D, C
If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs,
maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do
not restart the transfusion until the child’s condition has been medically evaluated.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 25: The Child With Cancer
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which is most descriptive of the pathophysiology of leukemia?
a. Increased blood viscosity occurs.
b. Thrombocytopenia (excessive destruction of platelets) occurs.
c. Immature cells that cannot function effectively predominate.
d. First stage of coagulation process is abnormally stimulated.
ANS: C
Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is
defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the
body. Increased blood viscosity may occur secondary to the increased number of WBCs.
Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.
The coagulation process is unaffected by leukemia.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Why would a child with leukemia receive central nervous system (CNS) directed intrathecal
chemotherapy in addition to systemic chemotherapy treatment?
Infection prevention for the central nervous system (CNS)
The leukemia cells in the CNS differ from systemic cells
The combination drug therapy will aid in the goal of complete remission
Leukemic cells are protected from systemic chemotherapy drugs by the bloodbrain barrier
a.
b.
c.
d.
ANS: D
CNS-directed therapy is based on the understanding that leukemic cells could be present in the
CNS where they are protected from many systemic chemotherapy drugs by the blood-brain
barrier. For this reason, all children receive CNS prophylactic therapy. The combination of
intrathecal chemotherapy (either methotrexate alone or in combination with cytarabine and
hydrocortisone) plus CNS-directed systemic chemotherapy (dexamethasone, L-asparaginase,
and high-dose methotrexate with leucovorin rescue) is standard; cranial radiation may be used
for children at highest risk for CNS relapse.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A hematopoietic stem cell transplant using stem cells donated by a sibling is which type of
transplant?
Syngeneic
Allogeneic
Monoclonal
Autologous
a.
b.
c.
d.
ANS: B
Allogeneic transplants are from another individual. Because he and his sibling are
histocompatible, the BMT can be done. Syngeneic marrow is from an identical twin. There is
no such thing as a monoclonal BMT. Autologous refers to the individual’s own marrow.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. Which immunization would not be given to a child receiving chemotherapy for cancer?
a. Tetanus vaccine
b. Inactivated poliovirus vaccine
c. Pertussis
d. Measles, rubella, mumps
ANS: D
The vaccine used for measles, mumps, and rubella is a live virus and can result in an
overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and diphtheria,
pertussis, tetanus (DPT) are not live virus vaccines.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
5. Which can be administered to prevent or control hemorrhage in a child with cancer?
a. Nitrosoureas
b. Platelets
c. Whole blood
d. Corticosteroids
ANS: B
Most bleeding episodes can be prevented or controlled with the administration of platelet
concentrate or platelet-rich plasma. Nitrosoureas, whole blood, and corticosteroids would not
prevent or control hemorrhage.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
6. Which is the most beneficial nursing action to prevent or minimize chemotherapy associated
nausea and vomiting?
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 30 minutes to 1 hour before chemotherapy begins.
d. Administer an antiemetic as soon as child has symptoms of nausea.
ANS: C
The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy
is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent
anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting.
Waiting until nausea and vomiting subside will help with this episode, but the child will have
the discomfort and be at risk for dehydration. Administering an antiemetic as soon as the child
has nausea does not prevent anticipatory nausea.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
7. Which point would the nurse include when talking to a child about alopecia secondary to
chemotherapy?
Explain to child that hair usually regrows in 1 year.
Advise child to expose head to sunlight to minimize alopecia.
Explain to child that wearing a hat or scarf is preferable to wearing a wig.
Explain to child that when hair regrows, it may have a different color or texture.
a.
b.
c.
d.
ANS: D
Alopecia is a side effect of certain chemotherapeutic agents. When the hair regrows, it may be
a different color or texture. The hair usually grows back within 3 to 6 months after cessation
of treatment. The head should be protected from sunlight to avoid sunburn. Children should
choose the head covering they prefer.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which is a common clinical manifestation of Hodgkin disease?
a. Petechiae
b. Bone and joint pain
c. Painful, enlarged lymph nodes
d. Enlarged, firm, nontender lymph nodes
ANS: D
Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common
presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and
joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding
associated with this tumor?
Abdominal distension
Weight gain
Hypotension
Increased urinary output
a.
b.
c.
d.
ANS: A
The initial assessment finding with a Wilms (kidney) tumor is abdominal swelling. Weight
loss, not weight gain, may be a finding. Hypertension occasionally occurs with a Wilms
tumor. Urinary output is not increased, but hematuria may be noted.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. The nurse is teaching nursing students about childhood nervous system tumors. Which
describes a neuroblastoma?
a. Diagnosis is usually made after metastasis occurs.
b. Early diagnosis is usually possible because of the obvious clinical manifestations.
c. It is the most common brain tumor in young children.
d. It is the most common benign tumor in young children.
ANS: A
Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is
made after metastasis occurs, with the first signs caused by involvement in the nonprimary
site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most
common malignant extracranial solid tumors in children. The majority of tumors develop in
the adrenal glands or the retroperitoneal sympathetic chain. They are not benign but
metastasize.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. The nurse is monitoring a 7-year-old child post surgical resection of an infratentorial brain
tumor. Which finding is immediately reported to the neurosurgeon?
Increased temperature
Decreased muscle strength
Unequal pupils
Depressed blink reflex
a.
b.
c.
d.
ANS: C
While all options would be documented upon assessment, the nurse would notify the
neurosurgeon immediately upon assessing dilated or unequal pupils. This may indicate
increased intracranial pressure (ICP) and potential brainstem herniation which are medical
emergencies.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Reduction of Risk Potential
12. In which position would the nurse place a 10-year-old child after a large tumor was removed
through a supratentorial craniotomy?
On the operative side with the bed flat
On the operative side with the head of bed elevated 20 to 30 degrees
On the operative side with the bed flat and pillows behind the head
On the operative side with the head of bed elevated 45 degrees
a.
b.
c.
d.
ANS: B
If a large tumor was removed, the child is not placed on the operative side because the brain
may suddenly shift to that cavity, causing trauma to the blood vessels, linings, and the brain
itself. The child with an infratentorial procedure is usually positioned on either side with the
bed flat. When a supratentorial craniotomy is performed, the head of bed is elevated 20 to 30
degrees with the child on either side or on the back. In a supratentorial craniotomy, the head
elevation facilitates CSF drainage and decreases excessive blood flow to the brain to prevent
hemorrhage. Pillows should be placed against the child’s back, not head, to maintain the
desired position.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity: Physiologic Adaptation
13. Which is the primary site of osteosarcoma?
a.
b.
c.
d.
Femur
Humerus
Pelvis
Tibia
ANS: A
Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak
incidence is between ages 10 and 25 years. More than half occur in the femur. After the femur,
most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. Metabolic abnormalities including hyperuricemia, hypocalcemia, hyperphosphatemia, and
hyperkalemia are hallmark signs of which condition?
Tumor lysis syndrome
Superior vena cava syndrome
Disseminated intravascular coagulation
Spinal cord compression
a.
b.
c.
d.
ANS: A
The metabolic abnormalities of tumor lysis syndrome include hyperuricemia, hypocalcemia,
hyperphosphatemia, and hyperkalemia. The crystallization of uric acid that can occur with
hyperuricemia can lead to acute renal failure. These metabolic changes are not seen in SVC
syndrome, DIC, or spinal cord compression.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. Children with leukemia may develop which underlying problem early in the disease? (Select
all that apply.)
a. Joint pain
b. Weight loss
c. Petechial hemorrhages
d. Changes within the muscles
e. Bruising without a cause
ANS: A, B, C, E
The onset of leukemia varies from acute to insidious. In most instances the child displays
remarkably few symptoms. For example, leukemia may be diagnosed when a minor infection,
such as a cold, fails to disappear completely. The child continues to be pale, listless, irritable,
febrile, and anorexic. Parents often suspect some underlying problem when they observe the
child’s weight loss, petechiae, bruising without cause, and continued complaints of bone and
joint pain. Muscle changes are not one of the main signs and symptoms of leukemia.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
2. Which interventions should the nurse use when caring for a child with mucositis secondary to
chemotherapy? (Select all that apply.)
Assist the child to use chlorhexidine mouthwash
Provide lemon glycerin swabs
Offer antifungal troches (lozenges)
Perform mouthcare every 2 to 4 hours
Rinse the mouth with a solution of diphenhydramine and Maalox
a.
b.
c.
d.
e.
ANS: A, D, E
Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate
(Peridex) because of its dual effectiveness against candidal and bacterial infections, antifungal
troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips moist. Agents
that should not be used include lemon glycerin swabs (irritate eroded tissue and can decay
teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of magnesia
(dries mucosa).
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
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 lot of drainage will come from the affected socket.
The face may be edematous or ecchymotic.
The eyelids will be sutured shut for the first week.
There will be an eye pad dressing taped over the surgical site.
The implanted sphere is covered with conjunctiva and resembles the lining of the
mouth.
a.
b.
c.
d.
e.
ANS: B, D, E
After enucleation surgery, the parents are prepared for the child’s facial appearance. An eye
patch is in place, and the child’s face may be edematous or ecchymotic. Parents often fear
seeing the surgical site because they imagine a cavity in the skull. A surgically implanted
sphere maintains the shape of the eyeball, and the implant is covered with conjunctiva. When
the eyelids are open, the exposed area resembles the mucosal lining of the mouth. The
dressing, consisting of an eye pad taped over the surgical site, is changed daily. The wound
itself is clean and has little or no drainage. So expecting a lot of drainage is not accurate to tell
parents. The eyelids are not sutured shut after enucleation surgery.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. The management of brain tumors in children consists of some or all of which therapies?
(Select all that apply.)
Surgery
Bone marrow transplantation
Chemotherapy
Stem cell transplantation
Radiation
Myelography
a.
b.
c.
d.
e.
f.
ANS: A, C, E
Treatment for brain tumors in children may consist of surgery, chemotherapy, and
radiotherapy alone or in combination. Bone marrow and stem cell transplantation therapies are
used for leukemia, lymphoma, and other solid tumors where myeloablative therapies are used.
Myelography is a radiographic examination after an intrathecal injection of contrast medium.
It is not a treatment.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which would be included in a teaching session on rhabdomyosarcoma tumors? (Select all that
apply.)
Tumor arises from mesenchymal cells
Most occur in children under 10 years of age
Most tumors occur in the chest cavity
More than half are of the embryonal histologic subtype
Because the tumor is benign, chemotherapy is not a part of treatment
a.
b.
c.
d.
e.
ANS: A, B, D
The initial signs and symptoms of rhabdomyosarcoma tumors are related to the site of the
tumor and compression of adjacent organs. Some tumor locations, such as the orbit, manifest
early in the course of the illness. Other tumors, such as those of the retroperitoneal area, only
produce symptoms when they are relatively large and compress adjacent organs.
Unfortunately, many of the signs and symptoms attributable to rhabdomyosarcoma are vague
and frequently suggest a common childhood illness, such as “earache” or “runny nose.” An
abdominal mass, sore throat and ear pain, and ecchymosis of conjunctiva are signs of a
rhabdomyosarcoma tumor. Bone fractures would be seen in osteosarcoma, and a headache is a
sign of a brain tumor.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
COMPLETION
1. A toddler with leukemia is on intravenous chemotherapy treatments. The toddler’s lab results
are WBC: 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. Which is this
child’s absolute neutrophil count (ANC)? _______ (Record your answer in a whole number.)
ANS:
140
To calculate an ANC for a WBC = 1000; neutrophils = 7%; and nonsegmented neutrophils
(bands) = 7%, the steps are
Step 1: 7% + 7% = 14%
Step 2: 0.14  1000 = 140
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 26: The Child With Genitourinary Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. Which test is the most useful clinical indication of glomerular filtration rate?
a. pH
b. Osmolality
c. Creatinine
d. Protein level
ANS: C
The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a
substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The
pH and osmolality are not estimates of glomerular filtration. Although protein in the urine
demonstrates abnormal glomerular permeability, it is not a measure of filtration rate.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which would the nurse recommend to prevent urinary tract infections in young girls?
a. Wear cotton underpants.
b. Limit bathing as much as possible.
c. Increase fluids; decrease salt intake.
d. Cleanse perineum with water after voiding.
ANS: A
Cotton underpants are preferable to nylon underpants. No evidence exists that limiting
bathing, increasing fluids/decreasing salt intake, or cleansing the perineum with water after
voiding decrease urinary tract infections in young girls.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which
finding in this newborn?
Absence of a urethral opening is noted.
Penis appears shorter than usual for age.
The urethral opening is along the dorsal surface of the penis.
The urethral opening is along the ventral surface of the penis.
a.
b.
c.
d.
ANS: D
Hypospadias is a congenital condition in which the urethral opening is located anywhere
along the ventral surface of the penis. The urethral opening is present, but not at the glans.
Hypospadias refers to the urethral opening, not to the size of the penis. A urethral opening
along the ventral surface of the penis is known as epispadias.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is conducting a staff in-service on newborn defects of the genitourinary system.
Which describes the narrowing of the preputial opening of the foreskin?
Chordee
Phimosis
Epispadias
Hypospadias
a.
b.
c.
d.
ANS: B
Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the
ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the
penis. Hypospadias is a congenital condition in which the urethral opening is located
anywhere along the ventral surface of the penis.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which is instituted for the therapeutic management of minimal change nephrotic syndrome?
a. Corticosteroids
b. Antihypertensive agents
c. Long-term diuretics
d. Increased fluids to promote diuresis
ANS: A
Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response
is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are
usually not necessary. A diet that has fluid and salt restrictions may be indicated.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
6. Which is included in the diet of a child with minimal change nephrotic syndrome?
a. High protein
b. Salt restriction
c. Low fat
d. High carbohydrate
ANS: B
Salt is usually restricted (but not eliminated) during the edema phase. The child has little
appetite during the acute phase. Favorite foods are provided (with the exception of high-salt
ones) in an attempt to provide nutritionally complete meals.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
7. Most cases of acute glomerulonephritis are associated with which of the following?
a. Urinary tract infection
b. Streptococcal infection
c. Renal vascular disorders
d. Structural anomalies of genitourinary tract
ANS: B
Acute poststreptococcal glomerulonephritis (APSGN) is the most common of the
postinfectious renal diseases in childhood and the one for which a cause can be established in
most cases. APSGN can occur at any age but affects primarily early school-age children, with
a peak age of onset of 6 to 7 years old. It is uncommon in children younger than 2 years old,
and boys outnumber girls 2 to 1.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
8. Which is the most common cause of acute renal failure in children?
a. Pyelonephritis
b. Tubular destruction
c. Urinary tract obstruction
d. Inadequate perfusion
ANS: D
The most common cause of acute renal failure in children is poor perfusion that may respond
to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes
of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most
common cause.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse is caring for a child with acute renal failure. Which clinical manifestation would the
nurse recognize as a sign of hyperkalemia?
Dyspnea
Seizure
Oliguria
Cardiac arrhythmia
a.
b.
c.
d.
ANS: D
Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia
include electrocardiograph anomalies such as prolonged QRS complex, depressed ST
segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not
manifestations of hyperkalemia.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. Advanced renal failure can result in which condition that results in retention of nitrogenous
product that produce toxic symptoms?
Uremia
Oliguria
Proteinuria
Pyelonephritis
a.
b.
c.
d.
ANS: A
Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is
diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the urine.
Pyelonephritis is an inflammation of the kidney and renal pelvis.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. Which is a major complication in a child with chronic renal failure?
a. Hypokalemia
b. Metabolic alkalosis
c. Water and sodium retention
d. Excessive excretion of blood urea nitrogen
ANS: C
Chronic renal failure leads to water and sodium retention, which contributes to edema and
vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen
are complications of chronic renal failure.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. One of the clinical manifestations of chronic renal failure is uremic frost. Which best
describes this term?
Deposits of urea crystals in urine
Deposits of urea crystals on skin
Overexcretion of blood urea nitrogen
Inability of body to tolerate cold temperatures
a.
b.
c.
d.
ANS: B
Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the
skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to
elevated levels. There is no relation between cold temperatures and uremic frost.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. Calcium carbonate is given with meals to a child with chronic renal disease. Which is the
purpose of administering calcium carbonate?
Prevent vomiting
Bind phosphorus
Stimulate appetite
Increase absorption of fat-soluble vitamins
a.
b.
c.
d.
ANS: B
Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal
absorption and the serum levels of phosphate. Serum calcium levels are increased by the
calcium carbonate, and vitamin D administration is necessary to increase calcium absorption.
Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of
fat-soluble vitamins.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
14. A preschool child is being admitted to the hospital with dehydration and a urinary tract
infection (UTI). Which urinalysis result would the nurse expect with these conditions?
WBC <1; specific gravity 1.008
WBC <2; specific gravity 1.025
WBC >2; specific gravity 1.016
WBC >2; specific gravity 1.030
a.
b.
c.
d.
ANS: D
WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary
tract inflammatory process. The urinalysis specific gravity for children with normal fluid
intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low
specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient
antidiuretic hormone secretion.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of
recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement
indicates the parents have understood the teaching?
a. “These injections will help with the hypertension.”
b. “We’re glad the injections only need to be given once a month.”
c. “The red blood cell count should begin to improve with these injections.”
d. “Urine output should begin to improve with these injections.”
ANS: C
Anemia in children with CRF is related to decreased production of erythropoietin.
Recombinant human erythropoietin (rHuEPO) is being offered to these children as thriceweekly or weekly subcutaneous injections and is replacing the need for frequent blood
transfusions. The parents understand the teaching if they say that the red blood cell count will
begin to improve with these injections.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. 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 would the nurse plan to
administer?
a. Spironolactone (Aldactone)
b. Sodium polystyrene sulfonate (Kayexalate)
c. Lactulose (Cephulac)
d. Calcium carbonate (Calcitab)
ANS: B
Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene
sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassiumsparing diuretic and should not be used if the serum potassium is elevated. Lactulose is
administered to reduce ammonia levels in patients with liver disease. Calcium carbonate may
be prescribed as a calcium supplement, but it will not reduce serum potassium levels.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
MULTIPLE RESPONSE
1. Which clinical manifestations would be expected in an upper or lower urinary tract infection
in an infant? (Select all that apply.)
Vomiting
Jaundice
Failure to gain weight
Swelling of the face
Persistent diaper rash
Dyspnea
a.
b.
c.
d.
e.
f.
ANS: A, C, E
Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations
observed in an infant with a UTI.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which are common features of acute glomerulonephritis? (Select all that apply.)
a. Oliguria
b. Hypotension
c. Hematuria
d. Proteinuria
e. Hypovolemia
ANS: A, C, D
Urinalysis during the acute phase characteristically shows hematuria and proteinuria.
Bacteriuria and changes in specific gravity are not usually present during the acute phase.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which clinical manifestations would the nurse expect to assess in a child admitted with
nephrotic syndrome? (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.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
COMPLETION
1. The nurse is performing a pH dipstick test on a urine specimen. Which is the median pH
expected for this test? _____ (Record your answer in a whole number.)
ANS:
6
The average pH for urine is 6. The normal range is 4.8 to 7.8. Abnormal pH levels are
associated with urinary infection and metabolic alkalosis or acidosis.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 27: The Child With Cerebral Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse has documented that a child’s level of consciousness is obtunded. Which describes
this level of consciousness?
Slow response to vigorous and repeated stimulation
Impaired decision making
Arousable with stimulation
Confusion regarding time and place
a.
b.
c.
d.
ANS: C
Obtunded describes a level of consciousness in which the child is arousable with stimulation.
Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and
repeated stimulation. Confusion is impaired decision making. Disorientation is confusion
regarding time and place.
DIF: Cognitive Level: Understand
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 would the nurse assess first?
a. A school-age child in a coma with stable vital signs
b. A preschool child with a head injury and decreasing level of consciousness
c. An adolescent admitted after a motor vehicle accident is oriented to person and
place
d. A toddler in a persistent vegetative state with a low-grade fever
ANS: B
The nurse should assess the child with a head injury and decreasing level of consciousness
first (LOC). Assessment of LOC remains the earliest indicator of improvement or
deterioration in neurologic status. The next child the nurse should assess is a toddler in a
persistent vegetative state with a low-grade fever. The school-age child in a coma with stable
vital signs and the adolescent admitted to the hospital who is oriented to his surroundings
would be of least worry to the nurse.
DIF: Cognitive Level: Apply
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 would record?
a. 8
b. 11
c. 13
d. 15
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal
response, and motor response. Numeric values of 1 through 5 are assigned to the levels of
response in each category. The sum of these numeric values provides an objective measure of
the patient’s level of consciousness (LOC). A person with an unaltered LOC would score the
highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is
scored at a 15.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the
child suddenly has a fixed and dilated pupil. How would the nurse interpret these findings?
Eye trauma
Neurosurgical emergency
Severe brainstem damage
Indication of brain death
a.
b.
c.
d.
ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse
should immediately report this finding. Although a dilated pupil may be associated with eye
trauma, this child has experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils
for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated
pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not
suggestive of brain death.
DIF: Cognitive Level: Analyze
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. Doll’s 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 intracranial pressure Delirium is a state of
mental confusion and excitement marked by disorientation for time and place. The doll’s head
maneuver is a test for brainstem or oculomotor nerve dysfunction.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is taking care of a child who is alert but showing signs of increased intracranial
pressure. Which test is contraindicated in this case?
Oculovestibular response
Doll’s head maneuver
Funduscopic examination for papilledema
Assessment of pyramidal tract lesions
a.
b.
c.
d.
ANS: A
The oculovestibular response (caloric test) involves the instillation of ice water into the ear of
a comatose child. The caloric test is painful and is never performed on a child who is awake or
one who has a ruptured tympanic membrane. Doll’s head maneuver, funduscopic examination
for papilledema, and assessment of pyramidal tract lesions can be performed on children who
are awake.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. Which is the priority nursing intervention for an unconscious child after a fall?
a. Establish adequate airway.
b. Perform neurologic assessment.
c. Monitor intracranial pressure.
d. Determine whether a neck injury is present.
ANS: A
Respiratory effectiveness is the primary concern in the care of the unconscious child.
Establishment of an adequate airway is always the first priority. A neurologic assessment and
determination of whether a neck injury is present will be performed after breathing and
circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after
airway, breathing, and circulation are maintained.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which drug would the nurse expect to administer to a preschool child who has increased
intracranial pressure (ICP) resulting from cerebral edema?
Mannitol (Osmitrol)
Epinephrine hydrochloride (Adrenalin)
Atropine sulfate (Atropine)
Sodium bicarbonate (Sodium bicarbonate)
a.
b.
c.
d.
ANS: A
For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used
most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium
bicarbonate are not used to decrease ICP.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
9. Which is an appropriate nursing intervention when caring for an unconscious child?
a. Change the child’s position infrequently to minimize the chance of increased ICP
b. Avoid using narcotics or sedatives to provide comfort and pain relief
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral
edema
d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated
ANS: C
Often comatose patients cannot cope with the quantity of fluids that they normally tolerate.
Overhydration must be avoided to prevent fatal cerebral edema. The child’s position should be
changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics
and sedatives should be used as necessary to reduce pain and discomfort, which can increase
ICP. Antipyretics are the method of choice for fever reduction.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. Which statement best describes a subdural hematoma?
a. Bleeding occurs between the dura and the skull.
b. Bleeding occurs between the dura and the arachnoid membrane.
c. Bleeding is generally arterial, and brain compression occurs rapidly.
d. The hematoma commonly occurs in the parietotemporal region.
ANS: B
A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of
a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs
between the dura and the skull, is usually arterial with rapid brain concussion, and occurs
most often in the parietotemporal region.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. An adolescent boy is brought to the emergency department after a motorcycle accident. His
respirations are deep, periodic, and gasping, with extreme fluctuations in blood pressure, and
pupils are dilated and fixed. The nurse would suspect which type of head injury?
a. Brainstem
b. Skull fracture
c. Subdural hemorrhage
d. Epidural hemorrhage
ANS: A
Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping
respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or
extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture,
subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. A child is unconscious after a motor vehicle accident. The watery discharge from the nose
tests positive for glucose. Which does this finding suggest?
Diabetic coma
Brainstem injury
Upper respiratory tract infection
Leaking of cerebrospinal fluid (CSF)
a.
b.
c.
d.
ANS: D
Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a
skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is
probably CSF from a skull fracture and does not signify whether the brainstem is involved.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is assessing a child who was just admitted to the hospital for observation after a
head injury. Which is the most essential part of the nursing assessment to detect early signs of
a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
ANS: D
The most important nursing observation is assessment of the child’s level of consciousness.
Alterations in consciousness appear earlier in the progression of an injury than do alterations
of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic
damage. Vital signs and focal neurologic signs are later signs of progression when compared
with level-of-consciousness changes.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. 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 would base her response
on which statement?
a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.
d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased
the frequency of this disease in children.
ANS: D
H. influenzae type B meningitis has been virtually eradicated in areas of the world where the
vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It
is significant because of the residual damage caused by undiagnosed and untreated or
inadequately treated cases. The leading causes of neonatal meningitis are the group B
streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of
bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of
the potential causative organisms.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. Which are the vector reservoirs for agents causing viral encephalitis in the United States?
a. Tarantula spiders
b. Mosquitoes
c. Carnivorous wild animals
d. Domestic and wild animals
ANS: B
Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by
mosquitoes. The vector reservoir for most agents pathogenic for humans and detected in the
United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the
hot summer months. Tarantula spiders, carnivorous wild animals, and domestic and wild
animals are not reservoirs for the agents that cause viral encephalitis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. When taking the history of a child hospitalized with Reye syndrome, the nurse would not be
surprised that a week ago the child had recovered from
measles.
varicella.
meningitis.
hepatitis.
a.
b.
c.
d.
ANS: B
Most cases of Reye syndrome follow a common viral illness such as varicella or influenza.
Measles, meningitis, and hepatitis are not associated with Reye syndrome.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. Which is the initial clinical manifestation of generalized seizures?
a. Being confused
b. Feeling frightened
c. Losing consciousness
d. Seeing flashing lights
ANS: C
Loss of consciousness is a frequent occurrence in generalized seizures and is the initial
clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are
clinical manifestations of a complex partial seizure.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
MULTIPLE RESPONSE
1. 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? (Select all that apply.)
a. “I should expect my child to have a few episodes of vomiting.”
b. “My child may have changes in her normal sleep patterns.”
c. “My child may have some behavioral changes after the accident.”
d. “My child may experience headaches after the fall.”
e. “I will limit my child’s physical activity for a minimum of one month.”
ANS: B, C, D
The parents are advised of probable posttraumatic symptoms that may be expected. These
include behavioral changes and sleep disturbances. If the child has these clinical signs, they
should be immediately reported for evaluation. Sleep disturbances are to be expected.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
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. Lower extremity spasticity
b. Sunken fontanel
c. Diplopia and blurred vision
d. Irritability
e. Distended scalp veins
f. Increased blood pressure
ANS: A, D, E
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP
in infants. Diplopia and blurred vision are indicative of elevated ICP in children. A highpitched cry and a tense or bulging fontanel are characteristics of increased ICP. Increased
blood pressure, common in adults, is rarely seen in children.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal
shunt. Which interventions would be included in the child’s postoperative care? (Select all
that apply.)
a. Observe closely for signs of infection.
b. Pump the shunt reservoir to maintain patency.
c. Administer sedation to decrease irritability.
d. Maintain Trendelenburg position to decrease pressure on the shunt.
e. Observe for signs of increased intracranial pressure.
f. Monitor for abdominal distention.
ANS: A, E, F
Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of
infection is a priority nursing intervention. Intake and output should be measured carefully.
Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping of the
shunt may cause obstruction or other problems and should not be performed unless indicated
by the neurosurgeon. Pain management rather than sedation should be the goal of therapy. The
child is kept flat to avoid too rapid a reduction of intracranial fluid.
DIF: Cognitive Level: Apply
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
e. Positive Gram stain
ANS: A, B, E
The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased
glucose, and increased protein content. There should not be RBCs evident in the CSF fluid.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which clinical manifestations would the nurse prepare to assess if bacterial meningitis is
confirmed? (Select all that apply.)
a. Headache
b. Photophobia
c. Bulging anterior fontanel
d. Seizures
e. Poor muscle tone
ANS: A, B, D
The onset of illness may be abrupt and rapid, or develop progressively over one or several
days, and may be preceded by a febrile illness. Most children with meningitis are seen with
fever, chills, headache, and vomiting that are associated with or quickly followed by
alterations in sensorium; however, some may present only with lethargy and irritability
(Weinberg & Thompson-Stone, 2018). The child is extremely irritable and agitated and may
develop seizures, photophobia, confusion, hallucinations, aggressive behavior, drowsiness,
stupor, or coma.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
6. 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
ANS: B, D, E
Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and
reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes
respirations.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
OTHER
1. A. Place in order the interventions the nurse would implement starting with the highest-
priority intervention sequencing to the lowest-priority intervention for a child experiencing a
generalized seizure. Provide the answer using lowercase letters separated by commas (e.g., A,
B, C, D, E).
a. Monitor vital signs.
b. Ease child to the floor.
c. Evaluate postictal symptoms.
d. Turn child to the side.
e. Note onset of seizure.
ANS:
E, B, D, A, C
The nurse would note the onset of the seizure and 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 would be taken next and the child
would be allowed to rest. Evaluate postictal symptoms such as confusion and return of speech.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 28: The Child With Endocrine Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time
for the GH to be administered?
At bedtime
After meals
Before meals
On arising in the morning
a.
b.
c.
d.
ANS: A
Injections are best given at bedtime to more closely approximate the physiologic release of
GH. After or before meals and on arising in the morning do not mimic the physiologic release
of the hormone.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
2. The nurse recognizes that treatment for a child with precocious puberty will involve the
injection of which synthetic medication?
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. Thyrotropin, gonadotropins, and somatotropic
hormone are not the appropriate therapies for precocious puberty.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
3. The nurse is caring for a preschool child with suspected diabetes insipidus. Which clinical
manifestation 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. Oliguria is decreased urine production and is not associated with diabetes insipidus.
Glycosuria is associated with diabetes mellitus. Nausea and vomiting are associated with
inappropriate antidiuretic hormone (ADH) secretion.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A nasal spray of desmopressin acetate (DDAVP) is used to treat which disorder?
a. Hypopituitarism
b. Diabetes insipidus
c. Acute adrenocortical insufficiency
d. Syndrome of inappropriate antidiuretic hormone
ANS: B
The drug of choice for the treatment of diabetes insipidus is DDAVP, which is a synthetic
analogue of vasopressin. DDAVP is not used to treat hypopituitarism, acute adrenocortical
insufficiency, or syndrome of inappropriate antidiuretic hormone.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
5. Which condition may cause exophthalmos (protruding eyeballs) in children?
a. Hypothyroidism
b. Hyperthyroidism
c. Hypoparathyroidism
d. Hyperparathyroidism
ANS: B
Exophthalmos is a clinical manifestation of hyperthyroidism. Hypothyroidism,
hypoparathyroidism, and hyperparathyroidism are not associated with exophthalmos.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is teaching the parents of a child who is receiving methimazole (Tapazole) for the
treatment of hyperthyroidism (Graves disease). Which statement made by the parent indicates
a correct understanding of the teaching?
a. “I would expect my child to gain weight while taking this medication.”
b. “I would expect my child to experience episodes of ear pain while taking this
medication.”
c. “If my child develops a sore throat and fever, I should contact the physician
immediately.”
d. “If my child develops the stomach flu, my child will need to be hospitalized.”
ANS: C
Children being treated with Tapazole must be carefully monitored for the side effects of the
medication. Parents must be alerted that sore throat and fever accompany the grave
complication of leukopenia. These symptoms should be immediately reported. Weight gain,
episodes of ear pain, and concern for hospitalization with the stomach flu are not concerns
related to taking Tapazole.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
7. A child with hypoparathyroidism is receiving vitamin D therapy. The parents would be
advised to watch for which sign of vitamin D toxicity?
a.
b.
c.
d.
Headache and seizures
Physical restlessness and voracious appetite without weight gain
Weakness and lassitude
Anorexia and insomnia
ANS: C
Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for
signs, including weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal
impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign
of vitamin D toxicity, but seizures are not. Physical restlessness and a voracious appetite with
weight loss are manifestations of hyperthyroidism. Anorexia and insomnia are not
characteristic of vitamin D toxicity.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
8. What is chronic primary adrenocortical insufficiency also called?
a. Graves disease
b. Addison disease
c. Cushing syndrome
d. Hashimoto disease
ANS: B
Addison disease is chronic adrenocortical insufficiency. Graves and Hashimoto diseases
involve the thyroid gland. Cushing syndrome is a result of excessive circulation of free
cortisol.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital
hyperplasia. Therapeutic management includes the administration of which substance?
Vitamin D
Cortisone
Stool softeners
Calcium carbonate
a.
b.
c.
d.
ANS: B
Cortisone is administered to suppress the abnormally high secretions of adrenocorticotropic
hormone (ACTH). This in turn inhibits the secretion of adrenocorticosteroid, which stems the
progressive virilization. Vitamin D, stool softeners, and calcium carbonate have no role in the
therapy of adrenogenital hyperplasia.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
10. Hyperglycemia associated with diabetic ketoacidosis is defined as a blood glucose
measurement equal to or greater than _____ mg/dl.
a. 100
b. 120
c. 180
d. 200
ANS: D
Diabetic ketoacidosis is a state of relative insulin insufficiency and may include the presence
of hyperglycemia, a blood glucose level greater than or equal to 200 mg/dl. The values 100
mg/dl, 120 mg/dl, and 180 mg/dl are too low for the definition of ketoacidosis.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. A child with diabetes mellitus presents to the clinic with a sore throat, cough, low-grade fever
and a blood glucose level of 245 mg/dl. The nurse instructs the parent to do which of the
following during the illness?
a. Decrease fluid intake during convalescence.
b. Check blood glucose levels every 30 minutes.
c. Provide high calorie snacks every few hours.
d. Urine testing for ketones every three hours.
ANS: D
DKA is a state of relative insulin insufficiency and may include the presence of
hyperglycemia (blood glucose level 200 mg/dl), ketonemia (strongly positive), acidosis (pH
<7.30 and bicarbonate <15 mmol/L), glycosuria, and ketonuria. It is recommended that urine
be tested for ketones every 3 hours during an illness or whenever the blood glucose level is
greater than 240 mg/dl when illness is not present. Fluid intake is increased. Blood glucose
checks would not be checked every 30 minutes, and high caloric snacks would further raise
blood glucose levels.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiological Integrity: Physiological Adaptation
12. The parents of a child who has just been diagnosed with type 1 diabetes asks about exercise.
Which would the nurse explain about exercise in type 1 diabetes?
Exercise will increase blood glucose.
Exercise should be restricted.
Extra snacks are needed before exercise.
Extra insulin is required during exercise.
a.
b.
c.
d.
ANS: C
Exercise lowers blood glucose levels, which can be compensated for by extra snacks. Exercise
lowers blood glucose and is encouraged and not restricted, unless indicated by other health
conditions. Extra insulin is contraindicated because exercise decreases blood glucose levels.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is implementing care for a school-age child admitted to the pediatric intensive care
in diabetic ketoacidosis (DKA). Which prescribed intervention would the nurse implement
first?
a. Begin 0.9% saline solution intravenously as prescribed.
b. Administer regular insulin intravenously as prescribed.
c. Place child on a cardiac monitor.
d. Place child on a pulse oximetry monitor.
ANS: A
All patients with DKA experience dehydration (10% of total body weight in severe
ketoacidosis) because of the osmotic diuresis, accompanied by depletion of electrolytes,
sodium, potassium, chloride, phosphate, and magnesium. The initial hydrating solution is
0.9% saline solution. Insulin therapy should be started after the initial rehydration bolus
because serum glucose levels fall rapidly after volume expansion. The child should be placed
on the cardiac and pulse oximetry monitor after the rehydrating solution has been initiated.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. A nurse is reviewing the laboratory results on a school-age child with hypoparathyroidism.
Which results are consistent with this condition?
Decreased serum phosphorus
Decreased serum calcium
Increased serum glucose
Decreased serum cortisol level
a.
b.
c.
d.
ANS: B
The diagnosis of hypoparathyroidism is made on the basis of clinical manifestations
associated with decreased serum calcium and increased serum phosphorus. A decreased serum
phosphorus level would be seen in hyperparathyroidism, elevated glucose in diabetes, and a
decreased serum cortisol level in adrenocortical insufficiency (Addison disease).
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. Nursing care of a child diagnosed with a syndrome of inappropriate ADH would include
which of the following? (Select all that apply.)
Weigh daily
Perform neurologic checks
Turn frequently
Maintain nothing by mouth (NPO)
Restrict fluids
a.
b.
c.
d.
e.
ANS: A, B, E
Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid volume
and decreases serum osmolarity with a progressive reduction in sodium concentration. The
immediate management of the child is to restrict fluids. The child should also be weighed at
the same time each day. Encouraging fluids will worsen the child’s condition. Turning
frequently is not an appropriate intervention unless the child is unresponsive. Fluids, not food,
should be restricted.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse would expect to assess which clinical manifestations in an adolescent with Cushing
syndrome? (Select all that apply.)
Hyperglycemia
Hyperkalemia
Hypotension
Cushingoid features
Susceptibility to infections
a.
b.
c.
d.
e.
ANS: A, D, E
In Cushing syndrome, physiologic disturbances seen are Cushingoid features hyperglycemia,
susceptibility to infection, hypertension, and hypokalemia.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. Which insulin preparations are rapid and short acting? (Select all that apply.)
a. Novolin N
b. Lantus
c. NovoLog
d. Novolin R
ANS: C, D
Rapid-acting insulin (e.g., NovoLog) reaches the blood within 15 minutes after injection. The
insulin peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular)
insulin (e.g., Novolin R) usually reaches the blood within 30 minutes after injection. The
insulin peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours. Intermediateacting insulins (e.g., Novolin N) reach the blood 2 to 6 hours after injection. The insulins peak
4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long-acting insulin (e.g.,
Lantus) takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16
hours after injection. The insulin stays in the blood between 20 and 24 hours.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. Which interventions would the nurse plan to implement for a child with juvenile
hypothyroidism? (Select all that apply.)
a. Moisturizer for dry skin
b. Antidiarrheal medications
c. Medications to help with insomnia
d. Implementation of thyroxine therapy
e. Stool softener
ANS: A, D, E
The presenting symptoms of juvenile hypothyroidism are myxedematous skin changes (dry
skin, puffiness around the eyes, sparse hair), constipation, lethargy, and mental decline. The
nurse should plan interventions for the dry skin and for the implementation of thyroxine
therapy. The child is prone to constipation and sleepiness so antidiarrheal medication and
medications to help with insomnia would not be appropriate.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is caring for a school-age child with hyperthyroidism (Graves disease). Which
clinical manifestations would the nurse monitor that may indicate a thyroid storm? (Select all
that apply.)
a. Constipation
b. Hypotension
c. Hyperthermia
d. Tachycardia
e. Vomiting
ANS: C, D, E
A child with a thyroid storm will have severe irritability and restlessness, vomiting, diarrhea,
hyperthermia, hypertension, severe tachycardia, and prostration.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
COMPLETION
1. A Hemoglobin A1c levels of less than _____% are a goal for adolescents with type 1 diabetes.
(Record your answer in a whole number.)
ANS:
7.5
The measurement of glycosylated hemoglobin (hemoglobin A1c) levels is a satisfactory
method for assessing control of the diabetes. As red blood cells circulate in the bloodstream,
glucose molecules gradually attach to the hemoglobin A molecules and remain there for the
lifetime of the red blood cell, approximately 120 days. The attachment is not reversible;
therefore, this glycosylated hemoglobin reflects the average blood glucose levels over the
previous 2 to 3 months. The test is a satisfactory method for assessing control, detecting
incorrect testing, monitoring the effectiveness of changes in treatment, defining patients’
goals, and detecting nonadherence. Hemoglobin A1c levels of less than 7.5% are a wellestablished goal at most care centers.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Chapter 29: The Child With Musculoskeletal or Articular Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication
would the nurse monitor related to the child’s immobilization status?
Metabolic rate increases
Increased joint mobility leading to contractures
Bone calcium increases, releasing excess calcium into the body (hypercalcemia)
Venous stasis leading to thrombi or emboli formation
a.
b.
c.
d.
ANS: D
The physiologic effects of immobilization, as a result of decreased muscle contraction, include
venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases
with immobilization. Loss of joint mobility leads to contractures. Bone demineralization with
osteoporosis and hypercalcemia occur with immobilization.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which can result from the bone demineralization associated with immobility?
a. Osteoporosis
b. Urinary retention
c. Pooling of blood
d. Susceptibility to infection
ANS: A
Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures,
extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of
immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects
of immobilization. Susceptibility to infection can result from the effects of immobilization on
the respiratory and renal systems.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A young girl has just injured her ankle at school. In addition to calling the child’s parents,
which is an immediate action by the school nurse?
Apply ice.
Observe for edema and discoloration.
Encourage child to assume a position of comfort.
Obtain parental permission for administration of acetaminophen or aspirin.
a.
b.
c.
d.
ANS: A
Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be
rested, be elevated, and have compression applied. Observing for edema and discoloration,
encouraging the child to assume a position of comfort, and obtaining parental permission for
administration of acetaminophen or aspirin are not immediate priorities. The application of ice
can reduce the severity of the injury.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A 10-year-old sustained a fracture in the epiphyseal plate of her right fibula from a fall. When
discussing this injury with her parents, the nurse would consider which statement?
Healing is usually delayed in this type of fracture.
Growth can be affected by this type of fracture.
This is an unusual fracture site in young children.
This type of fracture is inconsistent with a fall.
a.
b.
c.
d.
ANS: B
Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or
epiphyseal plate present special problems in determining whether bone growth will be
affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point
of the long bones. This is a frequent site of damage during trauma.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which is an advantage to using a fiberglass cast instead of a plaster of Paris cast?
a. Cost effective
b. Dries rapidly
c. Molds closely to body parts
d. Smooth exterior
ANS: B
A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which
takes 10 to 72 hours to dry. Synthetic casts are more expensive and have a rough exterior,
which may scratch surfaces. Plaster casts mold closer to body parts.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is
being discharged with a cast. Which instruction would be included in the teaching?
a. Swelling of the fingers is to be expected for the next 48 hours.
b. Immobilize the shoulder to decrease pain in the arm.
c. Allow the affected limb to hang down for 1 hour each day.
d. Elevate casted arm when resting and when sitting up.
ANS: D
The injured extremity should be kept elevated while resting and in a sling when upright. This
will increase venous return. Swelling of the fingers may indicate neurovascular damage and
should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints
above and below the cast on the affected extremity should be moved. The affected limb
should not hang down for any length of time.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. An adolescent with a fractured femur is in Russell’s traction. Surgical intervention to correct
the fracture is scheduled for the following morning. Nursing care would include which action?
Maintaining continuous traction until 1 hour before the scheduled surgery
Maintaining continuous traction and checking position of traction frequently
Releasing traction every hour to perform skin care
Releasing traction once every 8 hours to check circulation
a.
b.
c.
d.
ANS: B
When the muscles are stretched, muscle spasm ceases and permits realignment of the bone
ends. The continued maintenance of traction is important during this phase because releasing
the traction allows the muscle’s normal contracting ability to again cause malpositioning of
the bone ends. Continuous traction must be maintained to keep the bone ends in satisfactory
realignment. Releasing at any time, either 1 hour before surgery, once every hour for skin
care, or once every 8 hours would not keep the fracture in satisfactory alignment.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which is a type of skin traction with the legs in an extended position?
a. Dunlop
b. Bryant
c. Russell
d. Buck
ANS: D
Buck extension traction is a type of skin traction with the legs in an extended position. It is
used primarily for short-term immobilization, preoperatively with dislocated hips, for
correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease. Dunlop
traction is an upper-extremity traction used for fractures of the humerus. Bryant traction is
skin traction with the legs flexed at a 90-degree angle at the hip. Russell traction uses skin
traction on the lower leg and a padded sling under the knee. The combination of longitudinal
and perpendicular traction allows realignment of the lower extremity and immobilizes the hips
and knees in a flexed position.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. Which is an appropriate nursing intervention when caring for a child in traction?
a. Remove adhesive traction straps daily to prevent skin breakdown.
b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles.
c. Provide active range-of-motion exercises to affected extremity three times a day.
d. Keep the child in one position to maintain good alignment.
ANS: B
Traction places stress on the affected bone, joint, and muscles. The nurse must assess for
tightness, weakness, or contractures developing in the uninvolved joints and muscles. The
adhesive straps should be released or replaced only when absolutely necessary. Active,
passive, or active with resistance exercises should be carried out for the unaffected extremity
only. Movement is expected with children. Each time the child moves, the nurse should check
to ensure that proper alignment is maintained.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. The nurse is teaching a family how to care for their infant in a Pavlik harness to treat
developmental dysplasia of the hip. Which would be included?
Apply lotion or powder to minimize skin irritation.
Remove harness several times a day to prevent contractures.
Do not make adjustments on the harness.
Place diaper over harness, preferably using a superabsorbent disposable diaper that
is relatively thin.
a.
b.
c.
d.
ANS: C
Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1
to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness.
The harness should not be removed, except as directed by the practitioner. A thin disposable
diaper can be placed under the harness.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the
nurse how this will be corrected, the nurse would give which explanation?
a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.
ANS: C
Serial casting is begun shortly after birth before discharge from nursery. Successive casts
allow for gradual stretching of skin and tight structures on the medial side of the foot.
Manipulation and casting of the leg are repeated frequently (every week) to accommodate the
rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is
done only if serial casting is not successful. Children do not improve without intervention.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing
considerations would include which action?
Encouraging normal activity for as long as is possible
Explaining the cause of the disease to the child and family
Preparing the child and family for long-term, permanent disabilities
Teaching the family the importance of activity restrictions
a.
b.
c.
d.
ANS: D
The family needs to learn the purpose, function, application, and care of the corrective device
and the importance of compliance to achieve the desired outcome. The initial therapy is rest
and non–weight bearing, which helps reduce inflammation and restore motion. Legg-CalvéPerthes is a disease with an unknown etiology. A disturbance of circulation to the femoral
capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is
self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and
the child’s age at onset.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is taking care of an adolescent diagnosed with kyphosis. Which describes this
condition?
Lateral curvature of the spine
Immobility of the shoulder joint
Exaggerated concave lumbar curvature of the spine
Increased convex angulation in the curve of the thoracic spine
a.
b.
c.
d.
ANS: D
Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.
Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation
causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint.
Lordosis is an exaggerated concave lumbar curvature of the spine.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. During which period of child development does idiopathic scoliosis become most noticeable?
a. Newborn period
b. When child starts to walk
c. Preadolescent growth spurt
d. Adolescence
ANS: C
Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. Idiopathic
scoliosis is seldom apparent before age 10 years. Diagnosis usually occurs during the
preadolescent growth spurt.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
15. The nurse is preparing an adolescent with scoliosis for a spinal surgical instrumentation
placement procedure. Which consideration would the nurse include?
a. A chest tube and urinary catheter may be required.
b. Ambulation will not be allowed for up to 3 months.
c. Surgery eliminates the need for casting and bracing.
d. Discomfort can be controlled with nonpharmacologic methods.
ANS: A
Surgical spinal instrumentation is a surgical procedure. A chest tube and urinary
catheterization may be required. Ambulation is allowed as soon as possible. Depending on the
instrumentation used, most patients walk by the second or third postoperative day. Casting and
bracing are required postoperatively. The child usually has considerable pain for the first few
days after surgery. Intravenous opioids should be administered on a regular basis.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. The nurse is caring for a 12-year-old child with a left leg below-the-knee amputation (BKA).
Which intervention would the nurse plan to implement for this child?
Elevate the left stump on a pillow.
Place an ice pack on the stump.
Full range of motion exercises of the joint above the amputation.
Replace the ace wrap covering the stump with a gauze dressing.
a.
b.
c.
d.
ANS: C
Use of the overhead bed trapeze should be encouraged to begin to build up the arm muscles
necessary for walking with crutches. Stump elevation may be used during the first 24 hours,
but after this time, the extremity should not be left in this position because contractures in the
proximal joint will develop and seriously hamper ambulation. Ice would not be an appropriate
intervention and would decrease circulation to the stump. Stump shaping is done
postoperatively with special elastic bandaging using a figure-eight bandage, which applies
pressure in a cone-shaped fashion. This technique decreases stump edema, controls
hemorrhage, and aids in developing desired contours so the child will bear weight on the
posterior aspect of the skin flap rather than on the end of the stump. This wrap should not be
replaced with a gauze dressing.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical
manifestations would the nurse expect to observe? (Select all that apply.)
Positive Ortolani click
Unequal gluteal folds
Negative Babinski sign
Trendelenburg sign
Telescoping of the affected limb
a.
b.
c.
d.
e.
ANS: A, B
A positive Ortolani test and unequal gluteal folds are clinical manifestations of developmental
dysplasia of the hip seen from birth to 2 to 3 months. Unequal gluteal folds, negative Babinski
sign, and Trendelenburg sign are signs that appear in older infants and children. Telescoping
of the affected limb and lordosis are not clinical manifestations of developmental dysplasia of
the hip.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. An adolescent with juvenile idiopathic arthritis (JIA) is prescribed methotrexate. Which would
the nurse teach the adolescent regarding this medication? (Select all that apply.)
Avoid receiving live immunizations while taking the medication.
All forms of alcohol must be avoided.
Sexually active teens need birth control.
Cushingoid features are likely to occur.
a.
b.
c.
d.
ANS: A, B, C
Abatacept reduces inflammation by inhibiting T cells and is given intravenously every 4
weeks. Possible side effects of biologics include an increased infection risk. Because of the
infection risk, children should be evaluated for tuberculosis exposure before starting these
medications. Live vaccines should be avoided while taking these agents.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse would
plan to implement which interventions for this child? (Select all that apply.)
Instructions to avoid exposure to sunlight
Teaching about body changes associated with SLE
Preparation for home schooling
Restricted activity
a.
b.
c.
d.
ANS: A, B
Key issues for a child with SLE include therapy compliance; body-image problems associated
with rash, hair loss, and steroid therapy; school attendance; vocational activities; social
relationships; sexual activity; and pregnancy. Specific instructions for avoiding exposure to
the sun and UVB light, such as using sunscreens, wearing sun-resistant clothing, and altering
outdoor activities, must be provided with great sensitivity to ensure compliance while
minimizing the associated feeling of being different from peers. The child should continue
school attendance in order to gain interaction with peers, and activity should not be restricted
but promoted.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is caring for a preschool child with a cast applied recently for a fractured tibia.
Which assessment findings indicate possible compartment syndrome? (Select all that apply.)
Palpable distal pulse
Capillary refill to extremity less than 3 seconds
Severe pain not relieved by analgesics
Tingling of extremity
Inability to move extremity
a.
b.
c.
d.
e.
ANS: C, D, E
Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of
extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the
extremity less than 3 seconds are expected findings.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Chapter 30: The Child With Neuromuscular or Muscular Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their
child’s spasticity. The nurse’s response would be based on which statement?
a. Anticonvulsant medications are sometimes useful for controlling spasticity.
b. Medications that would be useful in reducing spasticity are too toxic for use with
children.
c. Many different medications can be highly effective in controlling spasticity.
d. Implantation of a pump to deliver medication into the intrathecal space to decrease
spasticity.
ANS: D
Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes
with activities of daily living and ambulation. Anticonvulsant medications are used when
seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects
of the drugs that reduce spasticity. Few medications are currently available for the control of
spasticity.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
2. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive
care nursery. Which describes this newborn’s defect?
a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed
b. Herniation of the brain and meninges through a defect in the skull
c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural
elements
d. Visible defect with an external saclike protrusion containing meninges, spinal
fluid, and nerves
ANS: D
A myelomeningocele is a visible defect with an external saclike protrusion, containing
meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves
the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and
meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial
protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. The nurse is conducting a staff in-service on common problems associated with
myelomeningocele. Which common problem is associated with this defect?
Hydrocephalus
Craniostenosis
Biliary atresia
Esophageal atresia
a.
b.
c.
d.
ANS: A
Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniostenosis
is the preterm closing of the cranial sutures and is not associated with myelomeningocele.
Biliary and esophageal atresia is not associated with myelomeningocele.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is reviewing prenatal vitamin supplements with an expectant client. Which
supplement would be included in the teaching?
Vitamin A throughout pregnancy
Multivitamin preparations as soon as pregnancy is suspected
Folic acid for all women of childbearing age
Folic acid during the first and second trimesters of pregnancy
a.
b.
c.
d.
ANS: C
The widespread use of folic acid among women of childbearing age has decreased the
incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina
bifida. Folic acid supplementation is recommended for the preconception period and during
the pregnancy. Only 42% of women actually follow these guidelines.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
5. How much folic acid is recommended for women of childbearing age?
a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg
ANS: B
It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age
will prevent 50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0
mg are not the recommended dosages of folic acid.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
6. The nurse is talking to a parent with a child who has a latex allergy. Which statement by the
parent would indicate a correct understanding of the teaching?
a. “My child will have an allergic reaction if he comes in contact with yeast
products.”
b. “My child may have an upset stomach if he eats a food made with wheat or
barley.”
c. “My child will probably develop an allergy to peanuts.”
d. “My child should not eat bananas or kiwis.”
ANS: D
There are cross-reactions between latex allergies and a number of foods such as bananas,
avocados, kiwi, and chestnuts. Children with a latex allergy will not develop allergies to other
food products such as yeast, wheat, barley, or peanuts.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type
1). Which signs and symptoms are associated with this disease?
a. Spinal muscular atrophy
b. Neural atrophy of muscles
c. Progressive weakness and wasting of skeletal muscle
d. Pseudohypertrophy of certain muscle groups
ANS: C
Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic
form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive
weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells.
Kugelberg-Welander disease is a juvenile spinal muscular atrophy with a later onset. CharcotMarie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the
peroneal nerves. Progressive weakness is found of the distal muscles of the arms and feet.
Duchenne muscular dystrophy is characterized by muscles, especially in the calves, thighs,
and upper arms, which become enlarged from fatty infiltration and feel unusually firm or
woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy
(Werdnig-Hoffmann disease)?
Hyperactive deep tendon reflexes
Hypertonicity
Lying in the frog position
Motor deficits on one side of body
a.
b.
c.
d.
ANS: C
The infant lies in the frog position with the legs externally rotated, abducted, and flexed at the
knees. The deep tendon reflexes are absent. The child has hypotonia and inactivity as the most
prominent features. The motor deficits are bilateral.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular
dystrophy. The management plan would include which action?
Recommend genetic counseling.
Explain that the disease is easily treated.
Suggest ways to limit use of muscles.
Assist family in finding a nursing facility to provide child’s care.
a.
b.
c.
d.
ANS: A
Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive
gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and
their female offspring. No effective treatment exists at this time for childhood muscular
dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary
goal. It has been found that children who remain as active as possible are able to avoid
wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to
provide the child’s care is inappropriate at the time of diagnosis. When the child becomes
increasingly incapacitated, the family may consider home-based care, a skilled nursing
facility, or respite care to provide the necessary care.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. Which would be administered to a child with tetanus?
a. Nonsteroidal antiinflammatory drugs (NSAIDs) to reduce inflammation.
b. Muscle stimulants to counteract muscle weakness.
c. Bronchodilators to prevent respiratory complications.
d. Tetanus immunoglobulin therapy (TIG).
ANS: D
Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus.
Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the
threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants
are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully
evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may
be prescribed may cause respiratory depression. Bronchodilators would not be used unless
specifically indicated.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
11. The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding
would be reported as abnormal and considered as a possible sign of cerebral palsy?
Tonic neck reflex at 5 months of age
Absent Moro reflex at 8 months of age
Moro reflex at 3 months of age
Extensor reflex at 7 months of age
a.
b.
c.
d.
ANS: D
Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of
primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex
(beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally
disappears between 4 and 6 months of age. The crossed extensor reflex, which normally
disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with
the knee extended. Normally, the contralateral foot responds with extensor, abduction, and
then adduction movements. The possibility of CP is suggested if these reflexes occur after 4
months.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the
morning. Which intervention would the nurse plan for the care of the myelomeningocele sac?
Open to air
Covered with a sterile, moist, nonadherent dressing
Reinforcement of the original dressing if drainage noted
A diaper secured over the dressing
a.
b.
c.
d.
ANS: B
Before surgical closure, the myelomeningocele is prevented from drying by the application of
a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually
sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is
closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be
carefully cleansed if it becomes soiled or contaminated. The original dressing would not be
reinforced but changed as needed. A diaper is not placed over the dressing because stool
contamination can occur.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. The nurse is admitting a school-age child with suspected Guillain-Barré syndrome (GBS).
Which is a priority in the care for this child?
Monitoring intake and output
Assessing respiratory efforts
Placing on a telemetry monitor
Obtaining laboratory studies
a.
b.
c.
d.
ANS: B
Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized
because respiratory and pharyngeal involvement may require assisted ventilation, sometimes
with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in
the event of respiratory compromise, intravenous (IV) administration of immunoglobulin
(IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be
used. Intake and output, telemetry monitoring, and obtaining laboratory studies may be part of
the plan of care but are not the priority.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit.
Which health care provider prescription would the nurse clarify with the health care provider
before implementing?
a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time.
b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously.
c. Titrate oxygen to keep pulse oximetry saturations greater than 92.
d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback
every 12 hours.
ANS: D
The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic
therapy is not part of the management of infant botulism because the botulinum toxin is an
intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular
should not be administered because they may potentiate the blocking effects of the neurotoxin.
Treatment consists of immediate administration of botulism immune globulin intravenously
(BIG-IV) without delaying for laboratory diagnosis. Early administration of BIG-IV
neutralizes the toxin and stops the progression of the disease. The human-derived botulism
antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in infant
botulism. Approximately 50% of affected infants require intubation and mechanical
ventilation; therefore, respiratory support is crucial, as is nutritional support, because these
infants are unable to feed.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
MULTIPLE RESPONSE
1. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing
care for this child includes which action(s)? (Select all that apply.)
Monitoring and maintaining systemic blood pressure
Administering corticosteroids
Minimizing environmental stimuli
Discussing long-term care issues with the family
Monitoring for respiratory complications
a.
b.
c.
d.
e.
ANS: A, B, E
Spinal cord injury patients are physiologically labile, and close monitoring is required. They
may be unstable for the first few weeks after the injury. Corticosteroids are administered to
minimize the inflammation present with the injury. It is not necessary to minimize
environmental stimuli for this type of injury. Discussing long-term care issues with the family
is inappropriate. The family is focusing on the recovery of their child. It will not be known
until the rehabilitation period how much function the child may recover.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Which assessment findings would the nurse note in a school-age child with Duchenne
muscular dystrophy (DMD)? (Select all that apply.)
Lordosis
Gower sign
Kyphosis
Scoliosis
Waddling gait
a.
b.
c.
d.
e.
ANS: A, B, E
Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms
noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and
lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or
sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic
muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus
muscles. Kyphosis and scoliosis are not assessment findings with DMD.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. The nurse is conducting discharge teaching to parents of a preschool child with
myelomeningocele,(repaired at birth), being discharged from the hospital after a urinary tract
infection (UTI). Which would the nurse include in the discharge instructions related to
management of the child’s genitourinary function? (Select all that apply.)
a. Continue to perform the clean intermittent catheterizations (CIC) at home.
b. Administer the oxybutynin chloride (Ditropan) as prescribed.
c. Reduce fluid intake in the afternoon and evening hours.
d. Monitor for signs of a recurrent urinary tract infection.
e. Administer furosemide (Lasix) as prescribed.
ANS: A, D
Discharge teaching to prevent renal complications in a child with myelomeningocele include:
(1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of
regular emptying of the bladder, such as CIC taught to and performed by parents and selfcatheterization taught to children; (3) medications to improve bladder storage and continence,
such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited
and Lasix is not used to improve renal function for children with myelomeningocele.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. Which would the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with
Guillain-Barré syndrome (GBS)? (Select all that apply.)
Decreased protein concentration
Normal glucose
Fewer than 10 white blood cells (WBCs/mm3)
Elevated red blood cell (RBC) count
Elevated protein concentration
a.
b.
c.
d.
e.
ANS: B, C, E
Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF
analysis reveals an abnormally elevated protein concentration, normal glucose, and fewer than
10 WBCs/mm3. CSF fluid should not contain RBCs.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. Which early signs of infection would the nurse monitor on an infant with myelomeningocele?
(Select all that apply.)
a. Temperature instability
b. Irritability
c. Lethargy
d. Bradycardia
e. Hypertension
ANS: A, B, C
The nurse should observe an infant with unrepaired myelomeningocele for early signs of
infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and
hypertension are not early signs of infection in infants.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
COMPLETION
1. The health care provider has prescribed lorazepam (Ativan) intravenously 0.05 mg/kg/dose
every 6 hours prn as a muscle relaxant. The child weighs 22 pounds. How many milligrams of
Ativan would the nurse administer per dose? _____ (Record your answer using one decimal
place.)
ANS:
0.5
Find the child’s weight in kilograms by dividing 22 by 2.2 = 22/2.2 = 10 kg. Multiply the 0.05
mg dose by 10 = 0.05 mg  10 kg = 0.5 mg per dose.
DIF: Cognitive Level: Analyze
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
Chapter 31: The Child With Integumentary Dysfunction
Evolve Resources for Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse is caring for a 5-year-old child with impetigo contagiosa and the parents want to
know what will happen to their child’s skin after the infection has subsided and healed. Which
answer would the nurse give?
a. There will be no scarring if a secondary infection is prevented.
b. There may be some pigmented spots.
c. It is likely there will be some slightly depressed scars.
d. There will be some atrophic white scars.
ANS: A
Impetigo contagiosa tends to heal without scarring unless a secondary infection occurs.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Cellulitis often caused by which organism?
a. Herpes zoster
b. Candida albicans
c. Human papillomavirus
d. Streptococcus or Staphylococcus
ANS: D
Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually
responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C.
albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with
various types of human warts.
DIF: Cognitive Level: Remember
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. 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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse would expect which prescribed treatment for a child with warts?
a. Vaccination
b. Local destruction
c. Corticosteroids
d. Specific antibiotic therapy
ANS: B
Local destructive therapy individualized according to location, type, and number—including
surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and
laser therapies—is used. Vaccination is prophylaxis for warts and is not a treatment.
Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5. Herpes zoster is caused by the varicella virus and has an affinity for
a. sympathetic nerve fibers.
b. parasympathetic nerve fibers.
c. posterior root ganglia and posterior horn of the spinal cord.
d. lateral and dorsal columns of the spinal cord.
ANS: C
The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the
spinal cord, and skin. The zoster virus does not involve sympathetic or parasympathetic nerve
fibers and the lateral and dorsal columns of the spinal cord.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. Which
would the nurse expect the therapeutic management of this child to include?
Administering oral griseofulvin
Administering topical or oral antibiotics
Applying topical sulfonamides
Applying Burow solution compresses to affected area
a.
b.
c.
d.
ANS: A
Treatment with the antifungal agent griseofulvin is part of the treatment for the fungal disease
ringworm. Oral griseofulvin therapy frequently continues for weeks or months. Antibiotics,
sulfonamides, and Burow solution are not effective in fungal infections.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. Which primary clinical manifestation would the nurse expect to assess in a child with scabies?
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.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. The nurse is talking to the parents of a child with pediculosis capitis. Which would the nurse
include when explaining how to manage pediculosis capitis?
“You will need to cut the hair shorter if infestation and nits are severe.”
“You can distinguish viable from nonviable nits, and remove all viable ones.”
“You can wash all nits out of hair with a regular shampoo.”
“You will need to remove nits with an extra-fine-tooth comb or tweezers.”
a.
b.
c.
d.
ANS: D
Treatment consists of the application of pediculicide and manual removal of nit cases. An
extra-fine-tooth comb facilitates manual removal. Parents should be cautioned against cutting
the child’s hair short; lice infest short hair as well as long. It increases the child’s distress and
serves as a continual reminder to peers who are prone to tease children with a different
appearance. It is not possible to differentiate between viable and nonviable eggs. Regular
shampoo is not effective; a pediculicide is necessary.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. 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. Longsleeved shirts and long pants tucked into socks should be the attire. Early treatment of the
erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is
caused by a spirochete, not mycotic spores.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10. The nurse is examining a 12-month-old who was brought to the clinic for persistent diaper
rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds.
Which is most likely the cause of the diaper rash?
a. Impetigo
b. Candida albicans
c. Urine and feces
d. Infrequent diapering
ANS: B
C. albicans infection produces perianal inflammation and a maculopapular rash with satellite
lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads
peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact
with the diaper, but sparing the folds, are likely to be caused by chemical irritation, especially
urine and feces.
DIF: Cognitive Level: Understand
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the
nurse that she cannot afford to stay home with the child and miss work. The parent asks the
nurse if some medication will shorten the course of the illness. Which is the most appropriate
nursing intervention?
a. Reassure the parent that it is not necessary to stay home with the child.
b. Explain that no medication will shorten the course of the illness.
c. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
d. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat
chickenpox.
ANS: C
Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and
decreasing itching, lethargy, and anorexia. It is important the parent stay with the child to
monitor fever. Acyclovir lessens the severity of chickenpox. VariZIG is given only to highrisk children.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The community health nurse is teaching parents about prevention of the spread and
reoccurrence of pediculosis (head lice). Which would the nurse include in the teaching
session? (Select all that apply.)
a. Dryclean nonwashable items.
b. Spray the environment with an insecticide.
c. Seal nonwashable items in a plastic bag for 5 days.
d. Boil combs and brushes for 10 minutes.
e. Discourage sharing of personal items.
ANS: A, D, E
To prevent the spread and reoccurrence of pediculosis the nurse should teach the parents to:
dryclean nonwashable items, boil combs and brushes for 10 minutes or soak for 1 hour in a
pediculicide, and discourage the sharing of personal items, such as combs, hats, scarves and
other headgear. Spraying with insecticide is not recommended because of the danger to
children and animals. Nonwashable items should be sealed for 14 days in a plastic bag.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential