Child Health Nursing Partnering with Children and Families, 2E Jane W. Ball Test Bank.pdf (12)

Type:

Test Bank

Child Health Nursing Resource: Partnering with Children and Families Edition:

2nd Edition

Author(s):

Jane W. Ball Ruth C. Bindler Kay J. Cowen

For exam and test prep, contact excellentessaywriters@gmail.com

1. The nurse in a pediatric acute care unit is assigned the following tasks. Based on recognition that the action defined requires training beyond the preparation of a registered nurse, the nurse would refuse to: 1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic.

2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery.

3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support group options.

4. Diagnose a 6-year-old with diversional activity deficit related to placement in isolation.

Correct answer: 1 Rationale: 1. Advanced practice nurse practitioners perform assessment, diagnosis, and management of health conditions. The role of the pediatric nurse includes providing nursing assessment, direct nursing care interventions, client and family education at developmentally appropriate levels, client advocacy, case management, minimization of distress, and enhancement of coping.

2. Listening to concerns is within the expectations of a nurse in an acute care unit.

3. Providing information about support groups is within the expectations of the acute care unit.

4. Nursing diagnoses are the responsibility of the acute care unit.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 1-1: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.

2. Despite the availability of State Children’s Health Insurance Programs (SCHIP), many eligible children are not enrolled. The nursing intervention that can best help eligible children to become enrolled is: 1. Assessment of the details of the family’s income and expenditures.

2. Case management to limit costly, unnecessary duplication of services.

3. To advocate for the child by encouraging the family to investigate its SCHIP eligibility.

4 To educate the family about the need for keeping regular well-child visit appointments.

Correct answer: 3 Rationale: 1. Financial assessment is more commonly the function of a social worker.

2. The case management activity mentioned will not provide a source of funding.

3. In the role of an advocate, a nurse will advance the interests of another; by suggesting that the family investigate its SCHIP eligibility, the nurse is directing their action toward the child’s best interest.

4. While it is the nurse’s responsibility to educate the family, this intervention is not what will best help eligible children to become enrolled.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Intervention Learning Outcome 1-1: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.

3. A nurse is examining different nursing roles. Which best illustrates an advanced practice nursing role?

1. A registered nurse who is the manager of a large pediatric unit 2. A registered nurse who is the circulating nurse in surgery

3. A clinical nurse specialist working as a staff nurse on a medical–surgical pediatric unit 4.

A clinical nurse specialist with whom other nurses consult for her expertise in

caring for high-risk children Correct answer: 4 Rationale: 1. A registered nurse who is the manager of a large pediatric unit, or one who is a circulating nurse in surgery, is defined as a professional nurse, and has graduated from an accredited program in nursing and completed the licensure examination.

2. A registered nurse who is the manager of a large pediatric unit, or one who is a circulating nurse in surgery, is defined as a professional nurse, and has graduated from an accredited program in nursing and completed the licensure examination 3. A clinical nurse specialist working as a staff nurse on a medical–surgical pediatric unit might have the qualifications for an advanced practice nursing staff but is not working in that capacity.

4. A clinical nurse specialist with whom other nurses consult for expertise in caring for high-risk children would define an advanced practice nursing role. Advanced practice nurses have specialized knowledge and competence in a specific clinical area, and have earned a master’s degree.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 1-1: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.

4. The major focus of the nurse practitioner is on: 1. Leadership.

2. Physical and psychosocial clinical assessment.

3. Independent care of the high-risk chronic child.

4. Tertiary prevention Correct answer: 2 Rationale: 1. Leadership might be a quality of the NP, but it is not the major focus.

2. Physical and psychosocial clinical assessment is the major focus of the nurse practitioner (NP), who provides care in many different clinical settings.

3. NPs cannot provide independent care of the high-risk chronic child, but must work in collaboration with a physician.

4. The NP usually does not do tertiary prevention as a major focus.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 1-1: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.

5. The role of the professional registered nurse as an educator is to: 1. Provide primary care for high-risk children who are in hospital settings.

2. Provide primary care for healthy children.

3. Work toward the goal of informed choices with the family.

4. Obtain a physician consultation for any technical procedures at delivery.

Correct answer: 3 Rationale: 1. The nurse educator does not provide primary care for high-risk children in hospital settings.

2. The nurse educator does not provide primary care for healthy children.

3. The educator works with the family toward the goal of making informed choices through education and explanation.

4. The nurse educator does not obtain a physician consultation for technical procedures.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 1-1: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.

6. The nurse recognizes that the pediatric client is from a cultural background different from that of the hospital staff. The nurse identifies this as a potential problem, and sets a nursing goal to: 1. Overlook or minimize the cultural differences that exist.

2. Facilitate the family’s ability to comply with the care needed through education.

3. Impose the nurse’s cultural perspective on this family.

4.

Encourage complementary beneficial cultural practices as primary therapies.

Correct answer: 2 Rationale: 1. Since culture develops from social learning, attempts to ignore or minimize cultural consideration will result in mistrust, suspicion, or offenses that can have negative effects upon the health of children by reducing the resources available to promote health and prevent illness.

2. The incorporation of the family’s cultural perspective into the care plan through education is most likely to result in the family’s ability to accept medical care and comply with the regimen prescribed.

3. It is not appropriate for the nurse to impose any personal beliefs or perspectives on families.

4. Complementary therapy may be used later if other primary therapies prove to be ineffective.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process:Planning Learning Outcome 1-2: Understand the historical and current societal influences on pediatric health care and nursing practice.

7. The nurse demonstrates family-centered care by: 1. Encouraging family visitation.

2. Assuming total care for the client.

3. Expecting the child to perform self-care in activities of daily living.

4. Limiting visitation to four time periods per day.

Correct answer: 1 Rationale: 1. Encouraging visitation recognizes the family as a constant influence and support in a child’s life, and is the foundation for developing a trusting relationship with families.

2. Family-centered care does not involve assuming total care for the client.

3. Family-centered care involves more than expectations for the child.

4. Limiting visitation is the exact opposite of providing family-centered care.

Cognitive Level: Comprehension Client Need: Safe, Effective Care Environment Nursing Process: Application Learning Outcome 1-2: Understand the historical and current societal influences on pediatric health care and nursing practice.

8. A 7-year-old child has been admitted for acute appendicitis. The parents are questioning the nurse about expectations during the child’s recovery. Which information tool would be most useful in answering a parent’s questions about timing of key events?

1. Healthy People 2010 2. Critical clinical pathways 3. Child mortality statistics 4. National clinical practice guidelines Correct answer: 2 Rationale: 1. Healthy People 2010 contains objectives set by the U.S. government to improve the health and reduce the incidence of death in the twenty-first century 2. Critical clinical pathways are interdisciplinary documents provided by a hospital to suggest ideal sequencing and timing of events and interventions for specific diseases to improve efficiency of care and enhance recovery. These pathways serve as models outlining the typical hospital stay for individuals with specified conditions.

3. Child mortality statistics can be compared with those from other decades for the evaluation of achievement toward health care goals.

4. National clinical practice guidelines promote uniformity in care for specific disease conditions by suggesting expected outcomes from specific interventions.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 1-2: Understand the historical and current societal influences on pediatric health care and nursing practice.

9. Pediatric health care occurs along a continuum that reflects not only the settings of care, but also: 1. The recommendations of health care providers.

2. The home setting.

3. The complexity and range of care needed by individual children and their families.

4. Prenatal care.

Correct answer: 3 Rationale: 1. The continuum of pediatric health care does not include the recommendations of health care providers.

2. The home setting is not included in the pediatric health care continuum.

3. Pediatric health care occurs along a continuum that reflects not only the various settings of care but also the complexity and range of care needed by individual children and their families. For example, all children need health promotion and maintenance services; some will also need care for chronic conditions, acute illnesses, and injuries.

4. Prenatal care is not considered part of the continuum of health care, since the main focus is on the health of the mother.

Cognitive Level: Application Client Need: Safe, Effective Care Environment: Continuity of Care Nursing Process: Planning Learning Outcome 1-2: Understand the historical and current societal influences on pediatric health care and nursing practice.

10. The telephone triage nurse at a pediatric clinic knows that each call is important.

However, recognizing that infant deaths are most frequent in this group, the nurse must be extra attentive during the call from the parent of an infant who is: 1. Younger than 3 weeks old.

2. Of a Native American family.

3. Of a non-Hispanic black family.

4. Between 6 and 8 months old.

Correct answer: 1 Rationale: 1. Almost two-thirds of all infant deaths occur during the first 28 days after birth.

2. Native American and Alaskan natives experience an infant mortality rate of 8.3 per 100,000 live births.

3. During 2000, the infant mortality statistics for non-Hispanic blacks was 13.6 per 100,000 live births.

4. About two-thirds of infant deaths occur much earlier—in the first 28 days of life.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Planning

Learning Outcome: 1-3 Analyze the current causes of child morbidity and mortality, and identify opportunities for nurses to intervene.

11. When discussing injury prevention with the parents of a toddler, which statement indicates teaching has been successful? “The leading cause of death in children is: 1. “Congenital anomalies.”

2. “Infectious disease.”

3. “Unintentional injury.”

4. “Cancer.”

Correct answer: 3 Rationale: 1. The leading cause of death in children is unintentional injuries, not congenital anomalies.

2. Infectious disease is not the cause of most deaths in children. It is unintentional injuries.

3. The most common cause of death for children between 1 and 19 years of age is unintentional injury from motor vehicle crashes, drowning, fire, burns, firearms, and suffocation.

4. Cancer is not the leading cause of child mortality.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Evaluation

Learning Outcome: 1-3 Analyze the current causes of child morbidity and mortality, and identify opportunities for nurses to intervene.

12. With regard to child mortality statistics, which nursing intervention would be most effective in decreasing mortality from unintentional injury?

1. Educating parents about the benefits of immunizations 2. Teaching parents about proper use of vehicle restraint seats 3. Encouraging parents to obtain genetic counseling 4. Teaching children about dangers of contact sports Correct answer: 2 Rationale: 1. Since the most common cause of mortality in children is unintentional injury, educating about immunizations will not be most effective.

2. The most common cause of death for children between 1 and 19 years of age is unintentional injury. The major causes of death from unintentional injury in childhood include motor vehicle crashes, drowning, fires and burns, firearms, and suffocation.

3. Obtaining genetic counseling will not decrease mortality from unintentional injuries.

4. Teaching about the dangers of contact sports will not decrease mortality from unintentional injuries like burns, motor vehicle crashes, and suffocation.

Cognitive Level: Application Client Need: Safe, Effective Care Environment: Accident Prevention Nursing Process: Implementation

Learning Outcome: 1-3 Analyze the current causes of child morbidity and mortality, and identify opportunities for nurses to intervene.

13. With regard to child mortality statistics, which nursing intervention would be most effective in decreasing post-neonatal mortality?

1. Educating parents on acceptable feeding techniques 2. Educating parents on the importance of positioning the baby on his back whenever sleeping 3. Teaching parents about “baby-proofing” their home 4. Providing support for first-time mothers Correct answer: 2 Rationale: 1. Teaching acceptable feeding techniques is not the most effective intervention to decrease post-neonatal mortality.

2. Sudden infant death syndrome accounts for nearly 28% of deaths to infants in the postneonatal period (between 1 and 12 months of age). Positioning babies on their backs to sleep has significantly reduced the incidence of sudden infant death syndrome.

3. Baby-proofing homes will not decrease post-neonatal mortality.

4. Providing support for first-time mothers will not decrease post-neonatal mortality.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment Nursing Process: Implementation

Learning Outcome: 1-3 Analyze the current causes of child morbidity and mortality, and identify opportunities for nurses to intervene.

14. Despite the availability of State Children’s Health Insurance Program, families often fail to obtain coverage for eligible children because: 1. They believe their income is too high to qualify.

2. They do not see the importance of insurance coverage.

3. Families do not have adequate time to complete the enrollment process.

4. Parents do not value medical interventions for their children.

Correct answer: 1 Rationale: 1. Despite availability of SCHIP, many eligible children are not enrolled. Reasons families have not enrolled include belief that their income is too high to qualify; they have obtained other insurance; they have difficulty with the application process and required documentation; and they lack skills in negotiating the system to get coverage.

2. Most families do value insurance coverage, so this is not the reason for failing to obtain SCHIP coverage.

3. Families have adequate time to complete the enrollment process, but some do not believe they will qualify, and so do not try to enroll.

4. Parents do value medical interventions for their children, but some do not believe they can qualify, believing that their income is too high.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome: 1-3 Analyze the current causes of child morbidity and mortality, and identify opportunities for nurses to intervene.

15. A 12-year-old pediatric client is in need of surgery. The health care member who is legally responsible for obtaining informed consent for an invasive procedure is the: 1. Nurse.

2. Physician.

3. Unit secretary.

4. Social worker.

Correct answer: 2 Rationale: 1. A nurse cannot legally obtain informed consent for a procedure, but can witness the signature on the consent form.

2. Informed consent is legal preauthorization for an invasive procedure. It is the physician’s legal responsibility to obtain this, because it consists of an explanation about the medical condition, a detailed description of treatment plans, the expected benefits and risks related to the proposed treatment plan, alternative treatment options, the client’s questions, and the guardian’s right to refuse treatment.

3. The unit secretary cannot obtain or sign as a witness for an informed consent document.

4. A social worker is not responsible for obtaining informed consent for an invasive procedure.

Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 1-4: Contrast the policies for obtaining informed consent of minors with policies for adults.

16. A child is being prepared for an invasive procedure in the presence of the child’s babysitter. The single mother of the child has legal custody, but is not present. After details of the procedure are explained, the legal informed consent for treatment on behalf of a minor child will be obtained from: 1. The divorced parent without custody.

2. The cohabitating unmarried boyfriend of the child’s mother.

3. A grandparent who lives in the home with the child.

4. The babysitter with written proxy consent.

Correct answer: 4 Rationale: 1. In the case of divorced parents, the parent with custody might be the only parent allowed by some states to give informed consent.

2. Residence in the same household with a child does not authorize an adult to sign consent for treatment.

3. Residence in the same household with a child does not authorize an adult to sign consent for treatment.

4. A parent may grant proxy consent in writing to another adult so that children are not denied necessary health care.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 1-4: Contrast the policies for obtaining informed consent of minors with policies for adults.

17. A 12-year-old child is being admitted to the unit for a surgical procedure. The child is accompanied by two parents and a younger sibling. The level of involvement in treatment decision making for this child is: 1. That of an emancipated minor.

2. That of a mature minor.

3. That of assent.

4. None.

Correct answer: 3 Rationale: 1. An emancipated minor is a self-supporting adolescent who is not subject to the control of a parent or guardian.

2. A mature minor is a 14- or 15-year-old whom the state law designates as being able to understand medical risks and who is thus permitted to give informed consent for treatment.

3. Assent requires the ability to generally understand what procedure and treatments are planned, to understand what participation is required, and to make a statement of agreement or disagreement with the plan. Usually, in Piaget’s stage of formal operations, 11–13-year-olds should be able to problem-solve using abstract concepts, and are able to give valid assent when parents sign the informed consent.

4. The child has some involvement at age 12, so this answer is not correct.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning

Learning Outcome 1-4: Contrast the policies for obtaining informed consent of minors with policies for adults.

18. When parents are divorced and have joint custody, who may give informed consent for treatment of the child?

1. Both parents must agree and give consent.

2. The custodial parent 3. Either parent 4. Designated medical social worker Correct answer: 3 Rationale:

1. It is not necessary for both parents to agree and give consent. 2. The non-custodial parent also may give informed consent in most states. 3. Informed consent is a formal authorization by the child’s parent or guardian allowing an invasive procedure. When parents are divorced, and have joint custody, either parent may give informed consent in most cases. 4. A designated medical social worker cannot give informed consent for a child unless that child has been taken into her department’s custody. Cognitive Level: Application Client Need: Safe, Effective Care Environment

Nursing Process: Planning Learning Outcome 1-4: Contrast the policies for obtaining informed consent of minors with policies for adults.

19. Emancipated minors are: 1. Economically self-supporting adolescents under 18 years of age, no longer living at home, and not subject to parental control.

2. Beginning to understand treatment risks.

3. Designated when child and parents do not agree.

4. Declared when there is a potential conflict of interest between the child and parents.

Correct answer: 1 Rationale: 1. Emancipated minors are economically self-supporting adolescents under 18 years of age, no longer living at home, and not subject to parental control. They can legally give informed consent for themselves.

2. Emancipated minors have more knowledge than just beginning understanding. They are solely responsible for themselves, and can give informed consent.

3. Emancipated minors are not designated only when the parents and child have a disagreement, but when the minor becomes solely responsible for all aspects of her life.

4. Emancipated minors are not declared as such only when there is a conflict of interest between the child and parents. The child has sole responsibility for all aspects of her life.

Cognitive Level: Comprehension

Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 1-4: Contrast the policies for obtaining informed consent of minors with policies for adults.

20. A nurse is working with pediatric clients in a research facility. The nurse recognizes that federal guidelines are in place to delineate which pediatrics clients must give assent for participation in research trials. Based upon the client’s age, the nurse would seek assent from which children? (Select all that apply.)

1. The precocious 4-year-old starting as a cystic fibrosis research study participant 2. The 7-year-old leukemia client electing to receive a newly developed medication being researched 3. The 10-year-old starting in an investigative study for clients with precocious puberty 4.

The 13-year-old client beginning participation in a research program for ADHD

treatments Correct answer: 2, 3, 4 Rationale: 1. A 4-year-old is not old enough to understand any of the benefits and risks of the research trial, and is not required to assent.

2. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about health care procedures and

treatments, and give assent.

3. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments, and give assent.

4. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments, and give assent.

Cognitive Level: Application

Client Need: Psychological Integrity Nursing Process: Planning Learning Outcome 1-5: Identify unique pediatric legal and ethical issues in pediatric nursing practice.

21. A supervisor is reviewing the documentation of the nurses in the unit. The documentation that most accurately and correctly contains all the required parts for a narrative entry is the entry that reads: 1. “1630 Catheterized using an 8 French catheter, 45 ml clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother’s arms following catheter removal. M. May RN” 2. “1/9/05 2 P.M. g-tube accessed, positive air gurgle over stomach: 5 ml air injected, 10 ml residual stomach contents returned to stomach, Pediasure formula hung on Kangaroo pump infusing at 60 mL/hr for 1 hour. Child grunting intermittently throughout procedure. K. Earnst RN” 3. “4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. F. Luck RN”

4.

“Feb. ’05 Portacath assessed with Huber needle. Blood return present. Flushed

with NaCl sol., IV gammaglobulins hung and infusing at 30mL/hr. Child smiling and playful throughout the procedure. P. Potter, RN” Correct answer: 2 Rationale: 1. While the description of the procedure is appropriate, this documentation does not include the date the note was written.

2. The client record should include the date and time of entry, nursing care provided, assessments, an objective report of the client’s physiologic response, exact quotes if applicable, and the nurse’s signature and title.

3. This option appropriately describes the procedure but neglects to include the date and how the client tolerated it.

4. This note does not specify the exact date and time at which the portacath was accessed. It also does not include the size of Huber needle was used.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Intervention

Learning Outcome 1-5: Identify unique pediatric legal and ethical issues in pediatric nursing practice.

22. The pediatric nurse’s best defense against an accusation of malpractice or negligence is that the nurse: 1. Followed the physician’s written orders.

2. Met the Society of Pediatric Nurses standards of practice.

3. Is a nurse practitioner or clinical nurse specialist.

4. Was acting on the advice of the nurse manager.

Correct answer: 2 Rationale: 1. Following the physician’s written orders or acting on the advice of the nurse manager is not enough to defend the nurse from accusations, because the orders and/or advice could be wrong or unethical. 2. Meeting the Society of Pediatric Nurses standards of practice would cover the pediatric nurse against an accusation of malpractice or negligence because the standards are rigorous, and cover all bases of excellent nursing practice. 3. Being a clinical nurse specialist or nurse practitioner does not defend the nurse against these accusations if he does not follow the Society of Pediatric Nurses standards of practice. 4. Following the physician’s written orders or acting on the advice of the nurse manager is not enough to defend the nurse from accusations, because the orders and/or advice could be wrong or unethical.

Cognitive Level:Application Client Need: Safe, Effective Care Environment

Nursing Process: Planning Learning Outcome 1-5: Identify unique pediatric legal and ethical issues in pediatric nursing practice.

23. A nurse who tells family members the condition of a newborn baby without first consulting the parents would have committed: 1. A breach of privacy.

2. Negligence.

3. Malpractice.

4. A breach of ethics.

Correct answer: 1

Rationale: 1. A breach of privacy would have been committed in this situation, because it violates the right to privacy of this family. The right to privacy is the right of a person to keep his person and property free from public scrutiny (even other family members). 2. Negligence and malpractice are punishable legal offenses, and are more serious. 3. Negligence and malpractice are punishable legal offenses, and are more serious.

4. A breach of ethics would not apply to this situation.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 1-5: Identify unique pediatric legal and ethical issues in pediatric nursing practice.

24. Parents or guardians have authority to make choices about their child’s health care in almost all circumstances. In which situation would the parents or guardians not have such authority? When the child: 1. Begins to develop competence in health care decisions.

2. And parents do not agree on major treatment options.

3. Is able to understand concrete explanations.

4. Is considered to be a mature minor.

Correct answer: 2 Rationale: 1. The child would need to have more than just a beginning competence to nullify the parents’ authority.

2. Parents and guardians have absolute authority to make choices about their child’s health care except in these cases: • When the child and parents do not agree on major treatment options

• When the parents’ choice of treatment does not permit life-saving treatment for the child • When there is a potential conflict of interest between the child and parents, such as with suspected child abuse or neglect 3. Understanding concrete operations is a start, but is not enough to nullify the parents’ authority.

4. Being a mature minor does not eliminate the need to obtain the parents’ informed consent, as they still maintain authority over their child.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning

Learning Outcome 1-5: Identify unique pediatric legal and ethical issues in pediatric nursing practice.

1. The mother of a newly hospitalized pediatric patient asks the nurse about the advantages of “rooming in.” The nurse could say that which items are confirmed by research as benefits when a parent “rooms in”? (Select all that apply.)

1. Patients sleep more soundly.

2. Children require shorter recovery periods.

3. Children have less anxiety during procedures.

4. Patients require fewer analgesics after surgery.

Answer: 2, 3, 4

Rationale: 1. These research studies did not investigate the child’s sleep depth or patterns.

2. When parents stayed in the hospital with their child, research found that the child experienced shortened recovery periods, exhibited decreased anxiety during procedures, required less analgesics for pain relief after surgery, was quieter, had improved coping, and was happier.

These research studies did not investigate the child’s sleep depth or patterns.

3. When parents stayed in the hospital with their child, research found that the child experienced shortened recovery periods, exhibited decreased anxiety during procedures, required less analgesics for pain relief after surgery, was quieter, had improved coping, and was happier.

These research studies did not investigate the child’s sleep depth or patterns.

4. When parents stayed in the hospital with their child, research found that the child experienced shortened recovery periods, exhibited decreased anxiety during procedures, required less analgesics for pain relief after surgery, was quieter, had improved coping, and was happier.

These research studies did not investigate the child’s sleep depth or patterns.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 2-1 Describe family-centered care, and develop a nursing care plan for the child and family that integrates key concepts.

2. A 7-year-old client tells you, “Grandpa, Mommy, Daddy, and my brother live at my house.”

The nurse identifies this family type as a: 1. Binuclear family.

2. Extended family.

3. Gay and lesbian family.

4. Traditional nuclear family.

Answer: 2

Rationale: 1. A binuclear family includes divorced parents who have joint custody of their biological children; the children alternate spending varying amounts of time in the home of each parent.

2. An extended family contains a parent or a couple who share the house with their children and another adult relative.

3. A gay or lesbian family is comprised of two same-sex domestic partners; they might or might not have children.

4. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biological children of this union.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome: 2-2 Describe characteristics of different types of families.

3. During assessment of a child’s biological family history, it is especially important that the nurse asking the mother for information use the term “child’s father” instead of “your husband” in the situation of a: 1. Traditional nuclear family. 2. Traditional extended family.

3. Two-income nuclear family. 4. Heterosexual cohabitating informal stepfamily. Answer: 4

Rationale: 1. In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

2. In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

3. In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

4. The mother from the heterosexual cohabitating informal stepfamily does not have a husband; the nurse should be asking about the child’s father. In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 2-2 Describe characteristics of different types of families.

4. The community health nurse is assessing several families for various strengths and needs in regard to afterschool and backup child care arrangements. The family type that typically will benefit most from this assessment and subsequent interventions is the:

1. Binuclear family.

2. Extended family.

3. Single-parent family.

4. Traditional nuclear family.

Answer: 3

Rationale: 1. The binuclear family, the extended family, and the traditional nuclear family generally have at least two adults who can share in the care for and the nurturing of its children.

2. The binuclear family, the extended family, and the traditional nuclear family generally have at least two adults who can share in the care for and the nurturing of its children.

3. The single-parent family most typically lacks social, emotional, and financial resources.

Nursing considerations for such families should include referrals to options that will enable the parent to fulfill work commitments while providing the child with access to resources that can support the child’s growth and development.

4. The binuclear family, the extended family, and the traditional nuclear family generally have at least two adults who can share in the care for and the nurturing of its children.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 2-2 Describe characteristics of different types of families.

5. The community health nurse is making an initial visit to a family. The most effective and efficient way for the nurse to assess the parenting style in use is to: 1. Observe the parent interacting with the child for five minutes.

2. Ask, “What rule is hardest for your child to obey?”

3. Ask, “How do you handle situations that require limit setting?”

4. Ask the children how the parents set rules.

Answer: 4

Rationale: 1. A less complete picture of parenting style is obtained during a brief artificial observation.

2. Learning about rules is less helpful than is an explanation of enforcement efforts and success.

3. Learning about rules is less helpful than is an explanation of enforcement efforts and success.

4. Parental styles are assessed while the family explains how it handles situations that require limit setting. Learning about rules is less helpful than is an explanation of enforcement efforts and success.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 2-3 Identify four different parenting styles, and analyze their impact on child personality development.

6. The nurse is working on parenting skills with a group of mothers. The mother who would need the fewest discipline-related suggestions is the: 1. Authoritarian one.

2. Authoritative one.

3. Indifferent one.

4. Permissive one.

Answer: 2

Rationale: 1. Children in the authoritarian parenting family are denied the opportunity to develop some skills in the areas of self-direction, communication, and negotiation.

2. The authoritative parenting style is one that results in positive outcomes for the behavior and

learning of children. Nurses have observed that children from homes using this parental style more frequently have personalities manifesting self-reliance, self-control, and social competence.

These parents should be praised for using the preferred approach.

3. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

4. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 2-3 Identify four different parenting styles and, analyze their impact on child personality development.

7. The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. The nurse knows that observation most frequently is seen in families that employ the parenting style known as: 1. Authoritarian.

2. Authoritative.

3. Indifferent.

4. Permissive.

Answer: 3

Rationale: 1. Parents who favor the authoritarian style might exhibit a punitive attitude toward the child who is misbehaving, but are not disinterested.

2. Parents employing the authoritative style and the permissive style have children who report that “My parent loves me and shows affection regularly.”

3. Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children.

4. Parents using the permissive parenting style usually have children who do not learn the

socially acceptable limits of behaviors.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 2-3 Identify four different parenting styles, and analyze their impact on child personality development.

8. The nurse is working with a mother of three children on parenting skills. The nurse demonstrates a strategy that uses reward to increase positive behavior. This strategy is called: 1. Time-out.

2. Reasoning.

3. Behavior modification.

4. Experiencing consequences of misbehavior.

Answer: 3

Rationale: 1. Time-out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes.

2. Reasoning attempts to use explanation to end misbehavior.

3. Behavior modification identifies and gives rewards for desired behaviors.

4. Time-out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation

Learning Outcome: 2-3 Identify four different parenting styles, and analyze their impact on child personality development.

9. The nurse is assigned to a child in a spica cast for a fractured femur suffered in an automobile accident. The child’s teenage brother was driving the car, which was totaled. The nurse learns that the father lost his job three weeks ago, and that the mother has just accepted a temporary waitress job. An appropriate diagnosis for this family is: 1. Compromised Family Coping related to the effects of multiple simultaneous stressors.

2. Impaired Social Interaction (parent and child) related to the lack of family or respite support.

3. Interrupted Family Processes related to child with significant disability requiring alteration in family functioning.

4. Risk for Caregiver Role Strain related to child with a newly acquired disability and the associated financial burden.

Answer: 1

Rationale: 1. Compromised Family Coping related to the effects of multiple simultaneous stressors best fits the multiple crises to which this family is responding.

2. Lack of family members and lack of respite support were not mentioned in the scenario.

3. The spica cast might require alteration in family functioning; however, fractures generally are not considered a significant long-term disability.

4. The need for a spica cast is not considered a newly acquired disability.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome: 2-4 List the categories of family strengths that help families cope with stressors.

10. Several children arrived at the Emergency Department accompanied by only their fathers.

The nurse knows that the father who legally may sign emergency medical consent for treatment is: 1. The divorced one from the binuclear family.

2. The stepfather from the blended or reconstituted family.

3. The divorced one when the single-parent mother has custody.

4. The non-biologic one from the heterosexual cohabitating family.

Answer: 1

Rationale: 1. The divorced father from the binuclear family may sign informed consent, because he has equal legal rights with the mother under joint custody arrangements.

2. The non-biologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the non-biologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

3. The non-biologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the non-biologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

4. The non-biologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the non-biologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome: 2-5 Describe the effect of major family changes on children, including divorce, gaining a step-parent, being placed in foster care, and adoption.

11. The camp nurse is assessing a group of children attending summer camp. The nurse will expect which children to be most likely to have problems perceiving a sense of belonging?

1. Children whose parents divorced recently 2. Children who gained a step-parent recently 3. Children recently placed into foster care 4. Children adopted as infants Answer: 3

Rationale: 1. Children whose parents divorce often fear abandonment.

2. Children who gain a step-parent might have problems trusting the new parent.

3. Children in foster care are more likely to have problems perceiving a sense of belonging.

4. Infants who are adopted at birth can have minimal problems with acceptance when parents follow pre-adoption counseling about disclosure.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 2-5 Describe the effect of major family changes on children, including divorce, gaining a step-parent, being placed in foster care, and adoption.

12. A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing health care: family-focused care and family-centered care. The best example of a nursing action in the family-centered care approach would be when the nurse: 1. Tells the family what must be done for the family’s health.

2. Assumes the role of an expert professional to direct the health care.

3. As healthcare authority, intervenes for the child and family as a unit.

4. Confers with the family in deciding which health care option will be chosen.

Answer: 4

Rationale: 1. Telling the family what should be done is family-focused care. In family-focused care, the health care worker assumes the role of professional expert. Though a good way of providing pediatric health care, those participating in this type of care will miss contributions that the family brings to the health care meeting, as in family-centered care.

2. Directing the care as a professional is an example of family-focused care. In familyfocused care, the health care worker assumes the role of professional expert while missing the multiple contributions the family brings to the health care meeting.

3. Intervening for the family as a health care authority is an example of family-focused care.

In family-focused care, the health care worker assumes the role of professional expert while missing the multiple contributions the family brings to the health care meeting.

4. Conferring with the family exemplifies family-centered care. The benefit of employing the family-centered care philosophy is that the priorities and needs as seen by the family are addressed as a partnership between a family and a nurse develops.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome: 2-6 Review various family theories, and identify their application to the nursing process.

13. The nurse is assessing a family’s effective coping strategies and ineffective defensive strategies. The nurse will use the family social system theory known as: 1. Family stress theory.

2. Family development theory.

3. Family systems theory, as evolved from general systems theory.

4. The Resiliency Model of Family Stress, Adjustment, and Adaptation.

Answer: 1

Rationale: 1. Family stress theory determines an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families.

2. Family development theory suggests developmental tasks for families in each stage.

3. Family systems theory looks at the relationships among and between family members and the environment.

4. The Resiliency Model of Family Stress, Adjustment, and Adaptation discusses two levels of severity for crises; one requires adjustment, while the other requires adaptation.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 2-6 Review various family theories, and identify their application to the nursing process.

14. The nurse is assessing a family with a variety of tools. The family-assessment tool that identifies the degree of satisfaction with one’s family is the: 1. Calgary Family Assessment Model.

2. Family APGAR. 3. Family Adaptability and Cohesion Evaluation Scales III (FACES III).

4. Home Observation for Measurement of the Environment (HOME).

Answer: 3

Rationale: 1. The Calgary Family Assessment Model uses three categories to reveal information about a family’s strengths and problems.

2. The Family APGAR gives initial measurements about the adaptability, partnership, growth, affection, and resolve of a family.

3. The Family Adaptability and Cohesion Evaluation Scales III (FACES III) evaluates

differences between scores for an ideal family and the family in question to distinguish one’s level of satisfaction with one’s own family.

4. The Home Observation for Measurement of the Environment (HOME) focuses upon strategies for interacting with a child in the home to promote learning.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 2-7 Identify the advantages of using a family assessment tool.

15. A nurse is working with the family of a pediatric client. The nurse is planning to obtain an accurate family assessment. The initial step would be to: 1. Establish a trusting relationship with the family. 2. Select the most relevant family-assessment tool. 3. Focus primarily on the mother, while learning her greatest concern. 4. Observe the family in the home setting, since this step always proves indispensable. Answer: 1

Rationale: 1. Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment.

2. There is benefit when the tool used matches the family’s strengths and resources; however, selecting the most relevant family assessment tool is not indispensable to accuracy in the assessment.

3. Focusing primarily on the mother while learning her greatest concern is counterproductive, and prevents the nurse from acknowledging multiple perceptions held by the family’s members.

4. Observing the family in the home setting is recommended only in some cases.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment

Learning Outcome: 2-8 Identify a variety of family support services that might be available in a community.

Chapter 3 1. A nurse is working with an overweight pediatric client. Of the six diseases targeted by the Strategic Plan to Reduce and Ultimately Eliminate Health Disparities (National Institutes of Health, 2002), which ones would the nurse need to be aware of as having roots in pediatric obesity? (Select all that apply.)

1. Asthma 2. Diabetes 3. Infant mortality 4. Cardiovascular disease

Correct answer: 2, 4 Rationale: 1. Asthma is not targeted as one of the disease having roots in pediatric obesity.

2. Conditions such as diabetes have higher morbidity rates in certain cultural groups due to the high rate of obesity among the children of these groups.

3. Infant mortality is not significantly correlated to obesity.

4. Conditions such as cardiovascular disease have higher morbidity rates in certain cultural groups due to the high rate of obesity among the children of these groups.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 3-1 Discuss specific concepts related to culture such as diversity, race, ethnicity, and assimilation.

2. A Southern, nominally Pentecostal, African-American pediatric client is being assessed during admission. He has braided, black, kinky hair, and he celebrates Kwanzaa. The nurse should document his ethnicity and race on the nursing admission form as: 1. Ethnicity Southern, race Black.

2. Ethnicity Black, race African-American.

3. Ethnicity African American, race Black.

4. Ethnicity Pentecostal, race African-American.

Correct answer: 3 Rationale:

1. His regional affiliation is Southern and his race is Black.

2. His ethnicity is African-American, because ethnicity refers to the distinctive characteristics of one’s cultural background. His race is Black.

3. His ethnicity is African-American and his race is Black, because race refers to biological similarities.

4. His religion is Pentecostal, which would not be documented, as religion is not part of ethnicity or race. His race is Black.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 3-1Discuss specific concepts related to culture such as diversity, race, ethnicity, and assimilation.

3. The nurse is working with a child newly enrolled into an English-as-a-Second-Language class.

The nurse wants to teach the child about the importance of handwashing before meals and of not eating food dropped on the exam room floor. The best way to assimilate the nurse’s cultural values about hygienic nutrition is to:

1. Have the nurse model proper handwashing before examining the child, and throw out the dropped cookie.

2. Provide written materials in English about hygiene and diet for the client to take home.

3. Have the child repeat his interpretation of the information that was taught.

4. Schedule a medical interpreter to accompany the patient to his next visit.

Correct answer: 3 Rationale:

1. The purpose of modeled behavior could be misunderstood if it is not accompanied by an explanation.

2. Written materials in English hold minimal value for clients with limited understanding.

3. When an interpreter is not available, asking the client to repeat his understanding of what was taught reveals how concepts were understood.

4. In working with families with limited English proficiency, it is optimal to have a medical interpreter present for the entire visit. When teaching has been done, the nurse has a responsibility to assess client understanding; thus, an interpreter at the next visit will not help the nurse or the client now.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 3-1 Discuss specific concepts related to culture such as diversity, race, ethnicity, and assimilation.

4. The nurse in a multicultural health clinic recognizes that many cultures use non-Western means in combination with Western health care prescriptions to treat illness. The nurse needs to recognize that the individuals most likely to combine curanderismo with Western health care prescriptions are:

1. Asian-Americans 2. . Mexican-Americans 3. African-Americans.

4. Native Americans.

Correct answer: 2 Rationale:

1. Asian-Americans are most likely to combine acupuncture with Western health care prescriptions.

2. Mexican-Americans are most likely to combine curanderismo with Western health care prescriptions.

3. African-Americans are most likely to combine roots of voodoo, seen in Black Muslims, with Western health care prescriptions.

4. Native Americans are most likely to combine the work of a medicine man with Western health care prescriptions.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 3-2 Describe cultural influences on the family’s beliefs about health, illness, and treatments.

5. A nurse works in a multicultural area’s health clinic. Which major barrier does this nurse need to consider when she hears that many individuals, regardless of cultural background, are prevented from regular health care?

1.

Unwelcoming waiting rooms

2.

High costs and a lack of health care coverage

3.

Lack of service during hours to meet the needs of the population served

4.

Lack of knowledge on the part of health care providers about cultural approaches

Correct answer: 2 Rationale: 1. Welcoming waiting rooms and service during hours to meet the needs of the population served were found to enhance the use of health care services; lack thereof is not the major barrier.

2. The high cost and a lack of health care coverage are major barriers to some children of immigrant families, Haitians, Koreans, and Hispanics, as well as others.

3. Welcoming waiting rooms and service during hours to meet the needs of the population served were found to enhance the use of health care services; lack thereof is not the major barrier.

4. When health care providers lack knowledge about cultural approaches, it is a problem; however, financial concerns are a more universal barrier.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Planning

Learning Outcome: 3-3 Identify cultural disparities in health care and barriers to health care for the child and family.

6. Which are ways in which complementary and alternative medicine are used in child health care? (Select all that apply.)

1. To replace traditional Western medicine practices 2. To coincide with traditional Western medicine practices

3. To ensure the child will remain healthy 4. To maintain positive energy around the child 5. To keep the child’s body in balance Correct answer: 1, 2, 4, 5 Rationale: 1. Alternative therapies may be used instead of traditional Western medicine in child health care.

2. Alternative therapies are used instead of traditional Western medicine, Complementary therapies are often used with Western medicine in child health care.

3. Complementary and alternative therapies cannot ensure the child with remain healthy, but can be used to help prevent illnesses or assist in recovery from illnesses.

4. Energy fields are manipulated through practices such as Reiki and/or therapeutic touch may be used in child health care.

5. Therapeutic touch and massage and/or osteopathic manipulation may be used to balance the body in child health care.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3-4 Describe the various uses of complementary and alternative medicine in child health care.

7. Which is the priority nursing diagnosis for a child whose parents are using complementary therapies with their child?

1. Injury, risk for 2. Parenting, altered

3. Family Processes, altered 4. Gas Exchange, impaired Correct answer: 1 Rationale: 1. Injury, risk for is the priority nursing diagnosis when complementary therapies are in use, as the nurse must be concerned for the child’s safety with respect to side effects, risks, and other implications of the therapy in use with traditional Western medical treatments 2. There is no indication the parents are using inappropriate parenting styles.

3. There is no indication this family has altered family processes. The use of complementary therapies does not mean their processes are unusual.

4. The use of complementary therapies does not indicate impaired gas exchange.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome: 3-4 Describe the various uses of complementary and alternative medicine in child health care.

8. The charge nurse is reviewing the care plans written by the unit’s staff nurses. The charge nurse recognizes that the NANDA nursing diagnosis most likely to be construed as culturally biased and possibly offensive is: 1. Fear related to separation from support system during hospitalization.

2. Spiritual Distress related to discrepancy between beliefs and prescribed treatment.

3. Family Processes, interrupted related to shift in family roles secondary to demands of illness.

4. Noncompliance related to impaired verbal communication secondary to recent immigration from non–English-speaking area.

Correct answer: 4 Rationale: 1. This answer seeks to explain how the culturally sensitive nurse can partner with the families more effectively.

2. This answer seeks to explain how the culturally sensitive nurse can partner with the families more effectively.

3. This answer seeks to explain how the culturally sensitive nurse can partner with the families more effectively.

4. The phrase “impaired verbal communication” might be offensive because speaking a different language is not equivalent to being impaired, and noncompliance does not stem from misunderstanding.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome: 3-5Describe and examine the role of the nurse in promoting cultural competence.

9. The nurse is beginning to obtain information about the present illness and medical history from the child’s family. The “zones” of space that the nurse should plan to use include the:

1. Social zone. 2.

Public zone. 3.

Intimate zone. 4.

Personal zone.

Correct answer: 4 Rationale:

1. The social zone, 3–6 feet from the body, can be used when calling individuals from a waiting room.

2. The public zone involves a distance greater than 6 feet away from individuals, and is used during communications with larger groups.

3. The intimate zone of within 18 inches is used during physical assessment.

4. The personal zone, 18 inches to 3 feet, is used when talking to individuals during interviewing and history taking.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 3-5Describe and examine the role of the nurse in promoting cultural competence.

10. The nurse is working with a family who has recently immigrated to this country. The nurse has recently studied Purnell’s Model for Cultural Competence (2002), and wants to respond to the family in a culturally acceptable manner. The most appropriate assessment question(s) would be:

1. “In what places have you lived?” and “What do you miss about your native land?”

2. “When I discuss your child’s problem with you, how close to you should I stand?”

3. “What does eye contact indicate?” and “When do you want me to make eye contact?” 4. “What is the school system like in your native land?”

Correct answer: 1 Rationale: 1. Identification of information about the native land is the beginning component of Purnell’s Model for Cultural Competence.

2. Proximity, distance, and eye contact are concepts addressed by Giger and Davidhizar.

3. Proximity, distance, and eye contact are concepts addressed by Giger and Davidhizar.

4. Leninger’s sunrise model addresses educational differences Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment

Learning Outcome: 3-6 Apply strategies for nurses to achieve cultural competence when providing care to the child and family.

11. A nurse is working in a clinic where children from several cultures are seen. As a first step toward the goal of personal cultural competence, the nurse will: 1.

Enhance cultural skills.

2.

Gain cultural awareness.

3.

Seek cultural encounters.

4.

Acquire cultural knowledge.

Correct answer: 2

Rationale: 1. Ways to enhance cultural skill include learning a prevalent language or learning how to recognize health-manifesting skin color variations in different races.

2. Campinha-Bacote’s theory of cultural competence sees the health care professional in a state of ever-increasing cultural competence. One begins by gaining cultural awareness or by gaining an effective and cognitive self-awareness of personal worldview biases, beliefs, and so on.

3. Daily interactions with clients from diverse backgrounds allow the nurse to appreciate the uniqueness of individuals from varying backgrounds.

4. Another early step, acquiring cultural knowledge includes studying information about the beliefs, biological variations, and favored treatments of specific cultural groups.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 3-6 Apply strategies for nurses to achieve cultural competence when providing care to the child and family.

12. The nurse is reviewing the charts from a multicultural health clinic. The nurse needs to know that for three cultures, the listed first name is in fact the family name, while the individual’s given name is placed last. The three cultures with this variation are: 1. French, German, and Irish.

2. Brazilian, English, and Jewish.

3. Canadian, Egyptian, and Haitian.

4. Cambodian, Filipino, and Korean.

Correct answer: 4 Rationale:

1. In France, Germany, and Ireland, the family name is listed second.

2. In Brazil and England, and in Jewish culture, the family name is listed second.

3. In Canada, Egypt, and Haiti, the family name is listed second.

4. The listed first name is in fact the family name in Cambodian, Filipino, and Korean cultures.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 3-6 Apply strategies for nurses to achieve cultural competence when providing care to the child and family.

13. The nurse is working in the respiratory clinic. In assessing children for cystic fibrosis, the nurse recognizes that children from which genetic and biologic racial background are more likely to have assessment findings characteristic of cystic fibrosis?

1. Asian 2.

Black

3.

Hispanic 4.

White

Correct answer: 4 Rationale: 1. Asians and Native Americans are more likely to experience alcohol abuse due to metabolic mechanisms.

2. Blacks are more likely to experience obesity and sickle-cell disease.

3. Hispanics and Blacks have higher rates of lactose intolerance than those of other racial backgrounds.

4. White children of certain geographic origins are more likely to manifest diseases such as cystic fibrosis and celiac disease.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 3-7 Identify nursing assessment strategies for various components of culture.

14. During the assessment, the nurse notices that a Black baby has a darker,slightly bluish-hued patch about 5  7 cm on the buttocks and lower back. What is the nurse’s next action?

1. Call the Department of Social Services (DSS) to report this sign of abuse.

2. Confer with the physician the possibility of a bleeding tendency.

3. Ask the mother about the cause of the bruise.

4. Chart the presence of a Mongolian spot.

Correct answer: 4 Rationale: 1. The nurse who calls the DSS to report this patch as a sign of abuse will reveal ignorance in culturally competent assessments, and possibly provoke harassment of the family.

2. If choosing to confer with the physician, the nurse will reveal ignorance in culturally competent assessments.

3. Asking the mother about the cause of the bruise reveals cultural ignorance in a less damaging manner than does calling DSS. 4. The nurse will chart the presence of a Mongolian spot, such as is observed in races with dark skin tones.

Cognitive Level: Analysis Client Need: Physiological Integrity

Nursing Process: Assessment Learning Outcome: 3-7 Identify nursing assessment strategies for various components of culture.

15. The oncology nurse is working with patients from many cultural backgrounds. When assessing pain, the nurse should recall that members of which cultural group are more likely to remain quiet when experiencing severe pain?

1. Asian 2. Hispanic 3. Italian 4. Jewish

Correct answer: 1 Rationale: 1. Those from Asian cultures are more likely to remain quiet when experiencing pain than are those of other cultures.

2. Hispanic cultures are not less likely to express severe pain.

3. Italian cultures are not less likely to express severe pain.

4. Jewish cultures are not less likely to express severe pain.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 3-7 Identify nursing assessment strategies for various components of culture.

16. The nurse working in a multicultural clinic recognizes that when the purpose of teaching is to promote the health of individual children, this effort should be directed to the authority responsible for the health care decisions. Since the health care decisions primarily will be fatherdominated in a certain cultural group, the nurse should direct teaching efforts to the fathers in which of the following groups?

1. Appalachian 2. African-American 3. European-American 4. Native American

Answer: 1 Rationale: 1. Family dominance patterns in some Appalachian cultures are more likely to be patriarchal.

2. These patterns are matriarchal in some African-American cultures.

3. European-American cultures are usually more egalitarian.

4. Tribal elders might make the decisions in some Native American cultures.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome: 3-8 Discuss nursing interventions for providing culturally sensitive and competent care to the child and family.

17. The nurse in the tuberculosis clinic recognizes that different racial groups are known to metabolize isoniazid (INH) differently. Which racial group is most likely to experience overdose

and neuropathy with standard dosing regimens of isoniazid, because this group metabolizes INH at a slower rate?

1. Native American 2. Black 3. Japanese.

4. White

Answer: 1 Rationale:

1. Ninety percent of Native Americans metabolize isoniazid slowly, so individuals from this race require less medication to avoid neuropathic symptoms.

2. Greater than 50% of Blacks metabolize isoniazid slowly.

3. Only 7–34% of Japanese clients metabolize isoniazid slowly.

4. Less than 50% of Whites metabolize isoniazid slowly.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 3-8 Discuss nursing interventions for providing culturally sensitive and competent care to the child and family.

18. The nurse is working with a child whose religious beliefs differ from those of the general population. The best nursing intervention to use to meet the specific spiritual needs of this child and family is to:

1. Ask, “How does the child and family’s religious/spiritual beliefs impact their practices for health and illness?”

2. Show respect while allowing time and privacy for religious rituals.

3. Ask, “What do you think caused the child’s illness?”

4. Identify health care practices forbidden by religious or spiritual beliefs.

Correct answer: 2 Rationale:

1. Asking about practices, asking about possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

2. Showing respect while allowing time and privacy for religious rituals is an intervention.

3. Asking about practices, asking about possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

4. Asking about practices, asking about possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 3-8 Discuss nursing interventions for providing culturally sensitive and competent care to the child and family.

1. To avoid complications, the nurse will teach the child with a genetic disorder to maintain penicillin prophylaxis if the child has been diagnosed with: 1. Hereditary idiopathic scoliosis.

2. Klinefelter’s syndrome.

3. Sickle-cell disease.

4. Recklinghausen’s disease.

Correct answer: 3

Rationale: 1. The client with idiopathic scoliosis is experiencing an orthopedic deviation.

2. The client with Klinefelter’s syndrome has a chromosomal alteration.

3. The client with sickle-cell disease needs penicillin prophylaxis to avoid complications of infection.

4. The client with Recklinghausen’s disease has a genetic disorder affecting neural tissues.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 4-1 Discuss the role of genetic concepts in health promotion and maintenance.

2. Which parent comment shows understanding of the cause of the child’s genetic condition in such a way that the nurse can document that no further teaching about the cause is needed?

1. “Our child is like this because I sunbathed too much during the pregnancy when I carried him.”

2. “My nephews had chickenpox in my seventh month of pregnancy with him, so he got this way.”

3. “My child has this disease because the code in the genes just changed, and it is no one’s

fault.”

4. “I was angry on the day when he was conceived in the womb; that is why he got this sickness.”

Correct answer: 3

Rationale: 1. It needs to be reinforced to parents that the child is not this way because of something the parent did or did not do during the pregnancy, and she is not afflicted because of a superstitious credence, a sinful behavior, or a cultural belief. The parent needs to know the child has a genetic code that tells the cells to be this way, because of changes in the genes.

2. It needs to be reinforced to parents that the child is not this way because of something the parent did or did not do during the pregnancy, and she is not afflicted because of a superstitious credence, a sinful behavior, or a cultural belief. The parent needs to know the child has a genetic code that tells the cells to be this way, because of changes in the genes.

3. Scientific understanding of actual reason for a genetic condition will alleviate or reduce the guilt and shame that are wrongfully felt when the parent has misguided beliefs about its causes.

4. It needs to be reinforced to parents that the child is not this way because of something the parent did or did not do during the pregnancy, and she is not afflicted because of a superstitious credence, a sinful behavior, or a cultural belief. The parent needs to know the child has a genetic code that tells the cells to be this way, because of changes in the genes.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 4-1. Discuss the role of genetic concepts in health promotion and maintenance.

3. A couple is evaluated in the genetics clinic, and the male is found to be a carrier of an X-

linked dominant disorder. The couple asks the nurse what this means in regard to their future children. The nurse’s response will include the information that: 1. All girls born to the family will be affected.

2. All boys born to the family will be affected.

3. About 25% of the girls born to the family will be affected.

4. About 25% of the boys born to the family will be affected.

Correct answer: 1

Rationale: 1. Any child who receives the X chromosome from the father will have the defect.

2. None of the boys will receive the father’s X, so none will be affected.

3. All girls will receive the father’s X. 4. None of the boys will receive the father’s X, so none will be affected.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4-1. Discuss the role of genetic concepts in health promotion and health maintenance.

4. A mother trying to understand karyotyping for Down syndrome, trisomy 21, asks the nurse, “What does a karyotype of a normal cell nucleus show?” You would inform her that a karyotype shows a representation of all ___________ chromosomes that a normal cell nucleus contains.

Answer: 46 Rationale:

A normal human cell nucleus contains 46 chromosomes; the karyotype shows a pictorial representation of all 46 chromosomes lined up in pairs.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 4- 2. Integrate basic genetic concepts into child and family education and the reinforcement of information provided to patients by genetic professionals.

5. The nurse in the genetics clinic is helping mothers understand the causes of their children’s genetic disorders. The nurse will explain how monosomy from nondisjunction during meiosis caused the disorder in the child with: 1. Classic Turner’s syndrome. 2.

Mosaic Down syndrome. 3. Mosaic Edwards’ syndrome. 4. Duchenne’s muscular dystrophy. Correct answer: 1

Rationale: 1. Classic Turner’s syndrome is caused by monosomy resulting from nondisjunction during meiosis.

2. Mosaic Down syndrome is caused by trisomy resulting during mitosis several generations after conception.

3. Mosaic Edwards’ syndrome is caused by trisomy resulting during mitosis several generations after conception.

4. Duchenne’s muscular dystrophy has no relation to the cell division patterns, since it is an Xlinked recessive disease.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 4- 2. Integrate basic genetic concepts into child and family education and the reinforcement of information provided to patients by genetic professionals.

6. A parent asks about the differences between the manifestations of cystic fibrosis in his child and in another child with this disease. The parent should be taught that different gene alterations within one particular gene can result in a wide variation in patient manifestations. Correct understanding of teaching is proved when a parent states, “A mutation in one area of the CFTR gene on chromosome 7 accounts for more than 300 variations of severity in: 1. “Mucus production.”

2. “Intelligence.”

3. “Sleeplessness.”

4. “Hydrocephalus.”

Correct answer: 1

Rationale: 1. When a parent is able to tell the nurse, “A mutation in one area of the CFTR gene on chromosome 7 accounts for more than 300 variations of severity in mucus production,” he has restated details about the cause of a wide variation in cystic fibrosis manifestations.

2. This gene does not affect intelligence, sleep patterns, or hydrocephalus.

3. This gene does not affect intelligence, sleep patterns, or hydrocephalus.

4. This gene does not affect intelligence, sleep patterns, or hydrocephalus.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome: 4- 2. Integrate basic genetic concepts into child and family education and the reinforcement of information provided to patients by genetic professionals.

7. A family has had all five of their children born with a genetic disorder. The disorder is inherited as autosomal dominant. If this is not a statistical rarity, the likelihood would be that: 1. Both parents are carriers.

2. One parent is a carrier and the other parent is unaffected.

3. One parent has both chromosomes with the affected gene.

4. One parent has one chromosome affected and the other parent has none.

Correct answer: 3

Rationale: 1. If both parents are carriers, 25% of the children should be free of the disease.

2. For all five children to have the disorder, one parent would have to have both chromosomes affected.

3. It takes only one chromosome to cause the defect in the child. If one parent has both chromosomes affected, every child would receive the affected chromosome.

4. For all five children to have the disorder, one parent would have to have both chromosomes affected.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 4-3 Integrate genetic physical assessment and the use of a pedigree family history into delivery of nursing care.

8. During a sports physical, a client is found to have myopia, long digits, tall stature, an arm span greater than his height, scoliosis, and a hollow chest. The nurse should suspect: 1. Huntington’s chorea.

2. Marfan’s syndrome.

3. phenylketonuria.

4. Turner’s syndrome.

Correct answer: 2

Rationale: 1. The central nervous system disease Huntington’s chorea would not be found during a pediatric sports physical, since it usually does not manifest symptoms until age 25.

2. Marfan’s syndrome is characterized by an arm span greater than one’s height, a hollow chest, scoliosis, long digits, tall stature, and myopia.

3. An early sign of phenylketonuria is an offensive urine odor that is found shortly after birth.

4. Turner’s syndrome, a congenital endocrine disorder, manifests with short stature and amenorrhea.

Cognitive Level: Analysis Client Need: Safe, Effective Care Nursing Process: Implementation Learning Outcome: 4-4. Identify children or families with actual or potential genetic conditions, and initiate referrals to a genetics professional.

9. When a parent reports multiple male miscarriages, the nurse should confer with the health care provider about a possible genetics referral for which type of conditions?

1. Anticipation autosomal dominant conditions 2. Autosomal recessive conditions 3. X-linked recessive conditions 4. X-linked dominant conditions Correct answer: 3

Rationale:

1. There is a variation of classic Mendelian inheritance called anticipation autosomal dominant in which the mother is only mildly affected but the child has a congenital form.

2. Autosomal recessive conditions are very rare, since an individual must carry the altered gene on both of the paired chromosomes for disease to be caused; even when both parents are carriers, the chance for the disease to be expressed is only 25%.

3. Multiple male miscarriages can be a sign of X-linked recessive conditions that can be severe and can result in high mortality rates.

4. X-linked recessive conditions are passed on only by the mother, and each individual has a 50% chance to receive the gene, making females carriers and males expressers of disease.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning

Learning Outcome: 4-4. Identify children or families with actual or potential genetic conditions, and initiate referrals to a genetics professional.

10. The nurse is discussing genetic referral with the parents of children being seen in the pediatric clinic. The child who would benefit from a genetic referral is the child whose family has a history of: 1. Cleft lip and/or cleft palate, diaphragmatic hernia, or cataract.

2. Normocephalic head, euthyroid, or five digits per extremity.

3. Broad face, lower-extremity lichenification, or spider angiomas.

4. Prominent epicanthal folds, resonant lungs, or absent tinnitus in Asian families.

Correct answer: 1

Rationale: 1. Individuals with cleft lip and/or cleft palate, diaphragmatic hernia, or cataract in their family history might benefit from a genetic referral.

2. A normocephalic head, euthyroid, and five digits per extremity are normal findings.

3. Lower-extremity lichenification more likely is the result of environmental factors.

4. The traits of prominent epicanthal folds in Asian families and a broad face are more likely to be family traits than to be minor anomalies.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 4-4. Identify children or families with actual or potential genetic conditions, and initiate referrals to a genetics professional.

11. A nurse is reviewing the charts of children in the pediatric units to determine which parents would benefit from referral to the genetics clinic. The nurse recognizes that the parents of children with genetic and chromosomal disorders would benefit most from this referral.

Therefore, the nurse refers the parents of the: (Select all that apply.)

1. Child diagnosed at age 6 with cystic fibrosis.

2. Neonate born at 28 weeks with respiratory distress syndrome.

3. 2-year-old child who is terminally ill with a brain tumor.

4. Child with Fanconi’s syndrome being treated for anemia.

5. 4-year-old child with nephrotic syndrome.

Answer: 1, 4

Rationale: 1. Cystic fibrosis and Fanconi’s syndrome are both genetic disorders.

2. Although genetic disorders can lead to prematurity, there is no evidence that this child has a genetic disorder.

3. There is no evidence that brain tumors have genetic tendencies.

4. Cystic fibrosis and Fanconi’s syndrome are both genetic disorders.

5. Nephrotic syndrome and brain tumors are not known to be genetic disorders.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 4-5. Prepare children and their families for a genetic evaluation, and facilitate the genetic counseling process.

12. The nurse in the genetics clinic is working with families undergoing testing for genetic disease. If the initial testing is positive, more extensive testing is required to confirm: 1. Pre-implantation genetic diagnosis.

2. Prenatal diagnostic testing.

3. Newborn screening.

4. Carrier screening.

Correct answer: 3, newborn screening.

Rationale: 1. Results from pre-implantation genetic diagnosis, prenatal diagnostic testing, and carrier screening have higher levels of specificity and sensitivity.

2. Results from pre-implantation genetic diagnosis, prenatal diagnostic testing, and carrier screening have higher levels of specificity and sensitivity.

3. Newborn screening for phenylketonuria, or sickle-cell or maple syrup urine disease, when positive, must be confirmed with more extensive testing.

4. Results from pre-implantation genetic diagnosis, prenatal diagnostic testing, and carrier screening have higher levels of specificity and sensitivity.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 4-5. Prepare children and their families for a genetic evaluation, and facilitate the genetic counseling process.

13. During genetic testing, one parent is found to have a chromosomal abnormality without any physical or mental disability; however, the offspring inherit physical and/or mental disability. During patient education, the nurse explains that the type of individual who can have a chromosomal abnormality without any disability but can cause his offspring to receive chromosomal alterations and disability is the parent with: 1. Mosaicism. 2.

Dominant-gene

structural

chromosomal

inversions.

chromosomal 4.

deletions.

Dominant-gene

3.

structural

Dominant-gene

structural

chromosomal

balanced

translocations. Answer: 4

Rationale: 1. The individual with mosaicism will display varying degrees of disability, depending on the percentage of cells that are affected. The clinical consequences of inversion depend on how much genetic material was rearranged.

2. A genetic deletion, such as is seen with cri du chat syndrome, results from a deletion on chromosome 5.

3. Individuals with other dominant-gene chromosomal alterations will all manifest some physical or mental abnormality themselves.

4. The parent with balanced translocations can show no signs of physical or mental disability but cause offspring to receive chromosomal alterations, such as trisomy 21.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 4-6. Describe the significance of delivering genetic education and counseling follow-up in a professional manner.

14. Which statement by a pregnant woman indicates correct understanding of autosomal recessive inheritance teaching when both husband and wife have one sickle-cell trait gene? 1.

“If this baby carries the trait like I do, then my next child will have sickle-cell anemia.” 2.

“If this baby carries the trait like I do, then my next child still has a 25% chance of carrying the trait.”

3. “Regardless of whether this baby carries the gene, my next child still has a 50% chance of carrying the trait.”

4. “Regardless of whether this baby carries the gene, my next child still has a 75% chance of carrying the trait.”

Correct answer: 3

Rationale: 1. Each child has an equal chance of being a carrier or having the disease.

2. Each child has an equal chance of being a carrier or having the disease.

3. Inheritance patterns for autosomal recessive inheritance when both parents are carriers of the trait provide identical inheritance risks to each pregnancy, regardless of which inheritance patterns siblings received. Thus, all offspring have a 50% risk of being a carrier, a 25% possibility of receiving an altered disease-producing gene from both parents and experiencing the disease, and a 25% chance of receiving an unaltered gene from each parent and being unaffected.

4. Each child has a 50% chance of carrying the trait when both the mother and father carry the gene.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Evaluation Learning Outcome: 4-6. Describe the significance of delivering genetic education and counseling follow-up in a professional manner.

15. Parents of a baby who died shortly after birth from a genetic disorder have been referred to a genetics clinic. The physician has explained to the parents why the referral was made. Which statement by the parents indicates that they understand the reason for the referral?

1. “The genetics clinic will give us the information we need to decide whether we want to try again.”

2. “I’m afraid the genetics clinic will tell us we cannot have another baby.”

3. “I think going to the genetics clinic will help us get over the loss of our baby.”

4. “The genetics clinic will prevent this from happening to us again.”

Correct answer: 1

Rationale: 1. The genetics clinic provides information based on genetic findings about the risks of future pregnancies.

2. The clinic will not decide whether the parents can or should have future pregnancies.

3. Although information can help the grieving process, it will not resolve it.

4. The clinic cannot prevent the loss of another baby, but can assist the parents to understand why this baby did, and the risks of it’s occurring again.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 4-6. Describe the significance of delivering genetic education and counseling follow-up in a professional manner.

16. Advances in genetic screening provide information with high levels of certainty about genetic disorders a fetus might have. Which of the following is an ethical implication of these advances?

1. The nurse must be aware of parent feelings regarding the information available to them.

2. The nurse must be aware of his own personal feelings about the actions taken after the screening tests are completed.

3. The parents must be aware of the nurse’s feelings regarding the information available about the fetus.

4. The nurse must participate in actions that are completely contradictory to his personal ethics.

Answer: 2 Rationale: 1. There are no ethical implications for the nurse to be aware of parent feelings about genetic screening information. In fact, the nurse does not have to know the parent feelings.

2. The nurse must be aware of his own personal feelings about possible actions following genetic screening information.

3. There are no ethical implications of the parents’ being aware of the nurse’s feelings unless the nurse forces those feelings and the subsequent actions on the parents.

4. The nurse does not have to participate in any action contradictory to personal ethics.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 4-7 Discuss the implications of genetic advances on the role of nurses, with particular attention to spiritual, cultural, ethical, legal, and social issues.

17. It is more common for children with genetic disorders to live longer. What impact does this have on health care delivery for the nurse providing care for these children?

1. Nurses must be familiar with increasing numbers of genetic disorders and the care these children require.

2. Nurses should not spend much time at the bedside, as these children with eventually die of these disorders.

3. Health care delivery is becoming more complex, despite these children requiring less care as they age.

4. Health care delivery will become more and more expensive until children with genetic disorders will have to do without.

Answer: 1 Rationale: 1. As advances in genetics continue, nurses will need to become familiar with more disorders in order to provide appropriate care for these children.

2. Regardless of the time these children will survive, nurses must still spend time at the bedside in order to provide appropriate nursing care.

3. Children with genetic disorders typically require more care that is more complex.

4. Children with genetic disorders will obtain the care needed regardless of the expense.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome: 4-8. Discuss the significance of recent advances in human genetics and the impact on health care delivery.

1. While being comforted in the Emergency Department, the 7-year-old sibling of a pediatric trauma victim blurts out to the nurse, “It’s all my fault!

When we were fighting yesterday, I told him I wished he was dead!” The nurse, realizing that the child is experiencing magical thinking, should respond by: 1. Asking the child if he would like to sit down and drink some water. 2. Sitting the child down in an empty room with markers and paper so that can he draw a picture.

3. Calmly discussing the catheters, tubes, and equipment that the patient requires, and explaining to the sibling why the patient needs them.

4. Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have no control over whether an accident happens.

Answer: 4

Rationale: 1. Ignoring the child’s outburst will not help the child understand it really was not his fault.

2. Asking the child to draw a picture might be appropriate later, but the nurse first needs to make sure the child knows the trauma did not occur because of his statement.

3. Addressing the sibling’s needs and equipment reinforces the child’s magical thinking that the trauma was his fault.

4. Magical thinking is the belief that events occur because of one’s thoughts or actions, and the most therapeutic way to respond to this is to correct any misconceptions that the child might have and reassure him that he is not to blame for any accident or illness.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation

Learning Outcome: 5-1. Describe the major psychological theories of development as formulated by Freud, Erikson, Piaget, Kohlberg, social learning theorists, and behaviorists.

2. The nurse talking with the parents of a toddler who is struggling with toilet training reassures them their child is demonstrating a typical developmental stage that Erikson described as: 1. “Trust vs. mistrust.”

2. “Autonomy vs. shame and doubt.”

3. “Initiative vs. guilt.”

4. “Industry vs. inferiority.”

Answer: 2

Rationale: 1. Trust vs. mistrust is the stage where infants learn whether the environment and the people in it can be trusted.

2. Erikson’s stage of autonomy vs. shame and doubt marks a period of time when the toddler is trying to gain some independence while still wanting to please adults.

3. Preschool-age children, not toddlers, must work through initiative vs. guilt.

4. School-age children must work on who they are and what can be achieved through industry vs. lacking self-esteem.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 5-1. Describe the major psychological theories of development as formulated by Freud, Erikson, Piaget, Kohlberg, social learning theorists, and behaviorists.

3. Utilizing Bronfenbrenner’s ecologic theory of development, the nurse caring for a

child would discuss the parents’ work environment as part of an assessment of that child’s: 1. Macrosystem.

2. Exosystem.

3. Mesosystem.

4. Chronosystem.

Answer: 2

Rationale: 1. Political and cultural beliefs comprise a child’s macrosystem.

2. A child’s exosystem is composed of the settings that influence a child even though she is not in daily contact with that system.

3. The relationships of one microsystem to another involve a child’s mesosystem.

4. The chronosystem involves the perspective of time in the child’s life.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 5-2. Explain contemporary developmental approaches such as temperament theory, ecologic theory, and the resilience framework.

4. The parents of a 1-month-old infant are concerned that their baby seems different from their other child, and ask the nurse if this is normal. The nurse informs them that it is normal for babies to have different temperaments, and that according to the “temperament theory” of Chess and Thomas, one of the characteristics of the “slowto-warm-up” child is that he: 1. Shows a regularity in patterns of eating.

2. Displays a predominately negative mood.

3. Initially reacts to new situations by withdrawing.

4. Commonly has intense reactions to the environment.

Answer: 3

Rationale: 1. Showing regularity in patterns of eating is a characteristic of an “easy” child.

2. Displaying a predominately negative mood to the environment is a characteristic of “difficult” children.

3. Slow-to-warm-up children adapt slowly to new situations, and initially will withdraw.

4. Commonly having intense reactions to the environment is a characteristic of “difficult” children.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 5-2. Explain contemporary developmental approaches such as temperament theory, ecologic theory, and the resilience framework.

5. While in the pediatrician’s office for their child’s 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the child’s developmental level, the nurse should suggest which types of toys?

Select all that apply. 1. Soft toys that can be manipulated and mouthed 2. Toys that can pop apart and go back together 3. Jack-in-the-box toys 4. Toys with black-and-white patterns 5. Push-and-pull toys Answer: 2, 3, 5

Rationale: 1. 1-year-olds are more mobile, so they have less interest in placing toys in their mouth and more interest in toys that can be manipulated.

2. Both gross and fine motor skills are becoming more developed, and children at this age enjoy toys that can help them refine these skills.

3. Both gross and fine motor skills are becoming more developed, and children at this age enjoy toys that can help them refine these skills.

4. Babies at 12 months tend to enjoy more colorful toys.

5. Both gross and fine motor skills are becoming more developed, and children at this age enjoy toys that can help them refine these skills.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 5-3. Recognize major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents.

6. While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. The nurse is determining whether the infant has developed: 1. Object permanence.

2. Centration.

3. Transductive reasoning.

4. Conservation.

Answer: 1

Rationale: 1. A child who has developed object permanence has the ability to understand that even though

something is out of sight, it still exists.

2. Centration is when a child focuses on only one particular aspect of a situation.

3. Transductive reasoning is when a child connects two events in a cause–effect relationship because they have occurred at the same time.

4. Conservation is when a child knows that matter is not changed when its form is altered.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 5-3. Recognize major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents.

7. While planning a lecture on healthy lifestyle choices for a high school class, the school nurse should be aware that which of the following statements is most supported by current research?

1. Children with lower self-efficacy scores tend to have a lower consumption of high-fat foods.

2. The most effective way to prevent or lower obesity rates in adolescents is to present them with facts about dietary intake.

3. Children with lower self-efficacy scores have been associated with more frequent violent behaviors than have children with higher self-efficacy scores.

4. Approaches that address choices, consciousness, efficacy, and behavioral factors are unlikely to encourage adaptation of healthy lifestyles in adolescents.

Answer: 3 Rationale: 1, Research findings contradict the belief that children with lower self-efficacy eat less high-fat food.

2. There is no evidence that providing children with facts about dietary intake lowers obesity

rates.

3. Current research supports the validity of the statement.

4. Research shows no evidence that adaptation of healthy lifestyles in adolescents is related to choices, consciousness, efficacy, and behavioral factors.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 5-3. Recognize major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents.

8. A nurse is assessing language development in all the infants presenting at the doctor’s office for well-child visits. The child who would be expected to be verbalizing the words “dada” and “mama” is the child between the ages of: 1. 3 and 5 months.

2. 6 and 8 months.

3. 9 and 12 months.

4. 13 and 18 months.

Answer: 3

Rationale: 1. Both the 3–5-month-old range and 6–8-month-old ranges are too early to expect an infant to verbalize words.

2. Both the 3–5-month-old range and 6–8-month-old ranges are too early to expect an infant to verbalize words.

3. A child should be able to verbalize “mama” or “dada” to identify her parents by 1 year of age.

4. By 18 months, if a child is unable to verbalize “dada” and “mama”, the child should be further evaluated.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation Learning Outcome: 5-4. Synthesize information from several theoretical approaches to plan assessments of the child’s growth and developmental milestones.

9. While counseling the parents of a 6½-month-old infant, the most appropriate toy for the nurse to suggest would be a: 1. Soft, fluid-filled ring that can be chilled in the refrigerator.

2. Colorful rattle.

3. Jack-in-the-box toy.

4. Push-and-pull toy.

Answer: 1

Rationale: 1. Teething toys would be appropriate for this age.

2. The rattle might be better enjoyed by a 3–6-month-old infant.

3. The jack-in-the-box and push-and-pull toys are better suited for a 9–12-month-old child.

4. The jack-in-the-box and push-and-pull toys are better suited for a 9–12-month-old child.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 5-5. Plan nursing interventions that are appropriate for the child’s developmental state and that apply developmental theories and frameworks.

10. Two 3-year-olds are playing in a hospital playroom together. One is working on a puzzle, while the other is stacking blocks. The mother of one of the children scolds

them for not sharing their toys. The nurse counsels this mother that this is normal developmental behavior for this age, and the term for it is: 1. Cooperative play.

2. Associative play.

3. Parallel play.

4. Solitary play.

Answer: 3

Rationale: 1. Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole.

2. Associative play is characterized by children interacting in groups and participating in similar activities.

3. Parallel play is when two or more children play together, each engaging in her own activities.

4. Solitary play is when a child plays alone.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 5-5. Plan nursing interventions that are appropriate for the child’s developmental state and that apply developmental theories and frameworks.

11. A neonatal nurse who encourages parents to hold their baby and provides opportunities for kangaroo care most likely is demonstrating concern for which aspect of the infant’s psychosocial development?

1. Attachment 2. Assimilation 3. Centration 4. Resilience Answer: 1

Rationale: 1. Attachment is a strong emotional bond between a parent and child that forms the foundation for the fulfillment of the basic need of trust in the infant.

2. Assimilation describes the child’s incorporation of new experiences.

3. Centration is the ability to consider only one aspect of a situation at a time.

4. Resilience is the ability to maintain healthy function even under significant stress and adversity.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 5-5. Plan nursing interventions that are appropriate for the child’s developmental state and that apply developmental theories and frameworks.

12. While trying to inform a 5-year-old girl about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. The nurse’s best response would be: 1. “Please stop talking about your puppy. I need to tell you about your CT scan.”

2. Ignore the child’s responses and continue discussing the procedure.

3. “I’ll come back when you are ready to talk with me more about your CT scan.”

4. “You must be so excited to have a new puppy! They are so much fun. Now let me tell you again about going downstairs in a wheelchair to a special room.”

Answer: 4 Rationale: 1. Asking the child to stop talking about her puppy and then abruptly talking about the CT scan

will alienate the child, and possibly make her shut down.

2. Ignoring the child’s obvious lack of attention will not help prepare her for the upcoming procedure.

3. Coming back later is not usually an option, as radiological exams are scheduled for a certain time. The nurse needs to address the inattention, but should listen for a few moments before directing the patient’s attention.

4. When a child becomes engaged in a collective monologue, it is best to respond to the content of her conversation and then attempt to reinsert facts about the content that needs to be covered.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 5-5. Plan nursing interventions that are appropriate for the child’s developmental state and that apply developmental theories and frameworks.

13. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. The nurse caring for the child should assure the mother that this is a normal response for a child who has undergone surgery, and that it is a coping mechanism that children use called: 1. Repression.

2. Rationalization.

3. Regression.

4. Fantasy.

Answer: 3

Rationale: 1. Repression is the involuntary forgetting of uncomfortable situations.

2. Rationalization is an attempt to make unacceptable feelings acceptable.

3. The correct answer is regression, which is a return to an earlier behavior.

4. Fantasy is a creation of the mind to help deal with an unacceptable fear.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome: 5-6. Recognize risks to normal developmental progression, and plan assessments of the child’s development.

14. Prior to giving an intramuscular injection to a 2½-year-old child, the most appropriate statement by the nurse would be: 1. “We will give you your shot when your mommy comes back.”

2. “This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here, then I will hold the needle like this and say ‘one, two, three  go’ and give you your shot. After the shot is over with, I will hold the cotton ball until it stops bleeding and then put the Band-Aid on. Are you ready?”

3. “It is all right to cry, I know that this hurts. After we are done, you can go to the box and pick out your favorite sticker.”

4. “This is a magic sword that will give you your medicine and make you all better.”

Answer: 3 Rationale: 1. Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time.

2. Giving elaborate descriptions and using colorful language also are inappropriate, because the instructions are unclear and lengthy.

3. The most appropriate response would be to acknowledge the child’s feelings and give him something to look forward to.

4. The nurse should not make statements that are not true and might confuse the child.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 5-7. Use data collected during developmental assessments to plan appropriate nursing interventions that promote development of children and adolescents.

15. A 14-year-old with cystic fibrosis suddenly becomes noncompliant with the medication regime. The intervention by the nurse that would most likely improve compliance would be to: 1. Give the child a computer-animated game that presents information on the management of cystic fibrosis.

2. Arrange for the physician to sit down and talk to the child about the risks related to noncompliance with medications.

3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively.

4. Discuss with the child’s parents the privileges that can be taken away, such as a cell phone, if compliance fails to improve.

Answer: 3 Rationale: 1. Interest in games might begin to wane at this age.

2. Adult opinions, even from a physician, could be viewed negatively and challenged.

3. Providing an adolescent with positive role models who are in her peer group is the intervention most likely to improve compliance.

4. Threatening punishment could further incite rebellion.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 5-7. Use data collected during developmental assessments to plan appropriate nursing interventions that promote development of children and adolescents.

1. While the nurse is admitting a pediatric patient, the mother blurts out, “I think this hospital is the most disorganized, inefficient place I have ever been in!” The most therapeutic response for the nurse to make would be: 1. “Does your child have any allergies or take any medication routinely?” 2. “It sounds like you are upset with the care your child has received. Is that correct?” 3. “This hospital and its staff are extremely competent, and you are receiving the best possible care.”

4. “It happens to be very busy right now, and there are children much sicker than your child who need to be cared for first.”

Answer: 2

Rationale: 1. Asking another question instead of responding to the mother’s complaint is an example of ineffective communication techniques. This will do nothing to defuse the situation.

2. This response validates the mother’s perceptions, and provides an opportunity for the mother to clarify her concerns with the nurse and keep the lines of communication open.

3. Disagreeing with the mother at this point would not be a therapeutic response.

4. Making excuses is not considered responding therapeutically.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 6-1. Describe the major components of the communication process as they apply to nursing care of children and their families.

2. A nurse notices a client sitting at the edge of the chair, tapping her fingers, fidgeting, and blinking her eyes frequently. In planning this client’s care, the nurse should take into account that this client is most likely displaying nonverbal cues of: 1. Anger. 2. Interest. 3.

Anxiety. 4. Shyness. Answer: 3

Rationale: 1. A person who is experiencing anger might appear rigid or tense, clench her fist, or tap her fingers.

2. Someone who is interested typically looks the other person in the face, leans forward, has frequent eye contact, and/or touches the arm or hand of the other person.

3. All of these nonverbal behaviors typically are expressed in a person who is experiencing feelings of anxiety.

4. A person experiencing shyness might hide her hands and have minimal eye contact with the other person.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment

Learning Outcome: 6-2. Identify forms of communication, and their related concepts.

3. While caring for an adolescent with cystic fibrosis, the nurse would best demonstrate friendliness and interest by the nonverbal behavior of:

1. Standing over the client’s bed while talking with him.

2. Sitting at eye level and leaning forward while speaking with the client.

3. Making eye contact with the client only when necessary.

4. Crossing the legs and leaning back slightly in the chair while talking with the client.

Answer: 2

Rationale: 1. Standing over the client’s bed while talking with him might be perceived as dominating or intimidating to the client.

2. Sitting at eye level and leaning forward while speaking with the client is most likely to convey friendliness and warmth.

3. Making eye contact with the client only when necessary could convey shyness or boredom.

4. Crossing the legs and leaning back slightly in the chair while talking with the client could be interpreted as withdrawal.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 6-2. Identify forms of communication, and their related concepts.

4. An 8-year-old child states, “Whenever I have to stop playing my video game to take my medicine, I get very mad!” The most appropriate response for the nurse to make would be: 1. “You are telling me that you get mad. Tell me what you mean by mad.” 2.

“You need your medicine to get better; you know this.” 3. “You need to just quit acting like a baby and take your medicine like a big boy.” 4. “You are going to be just fine, you only have three more days to take this medicine.” Answer: 1

Rationale:

1. “You are telling me that you get mad. Tell me what you mean by mad” utilizes the therapeutic technique of clarifying.

2. “You need your medicine to get better; you know this” imposes the nurse’s own values on the child.

3. “You need to just quit acting like a baby and take your medicine like a big boy” is a stereotypical answer.

4. “You are going to be just fine, you only have three more days to take this medicine” does not address the child’s feelings, and gives false reassurance.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 6-2. Identify forms of communication, and their related concepts.

5. Students are observing a staff nurse who is empathic with the child undergoing chemotherapy.

The students observe the nurse interplaying the internalized feelings of the child and the child’s experiences or fantasies. The students recognize that the nurse, while fully absorbed in the identity of the child, still identifies himself as a separate personality. The student who correctly understands empathy recognizes the phase of empathy as: 1. Detachment.

2. Identification.

3. Reverberation.

4. Incorporation.

Answer: 4 Rationale: 1. Withdrawing from subjective involvement describes detachment.

2. Becoming absorbed in contemplating the child describes identification.

3. Interplaying the internalized feelings of the child correctly describes reverberation.

4. Taking in the experiences of the child describes incorporation.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 6-3. Identify factors influencing the communication process.

6. In order to prepare a 6-year-old client for an intravenous catheter insertion, the nurse’s best response would be: 1. “If I were you, I would hold very still so that it will only take one stick.”

2. “It is okay to cry. I know that this hurts.”

3. “Don’t worry a bit, this is just like a little mosquito bite.”

4. “Why are you crying? I thought that you were a tough kid.”

Answer: 2

Rationale: 1. “If I were you, I would hold very still so that it will only take one stick” has confusing terminology, and is advising the child on what he should do.

2. “It is okay to cry. I know that this hurts” is an accepting response that lets a child know that it is okay to express feelings.

3. “Don’t worry a bit, this is just like a little mosquito bite” gives false reassurance.

4. “Why are you crying? I thought that you were a tough kid” belittles the child’s expressed feelings.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 6-4. Apply concepts of communication to the developmental levels of childhood.

7. During a well-child visit, a frustrated mother complains that her 2-year-old’s only response anymore is “no,” and asks for help. The most appropriate advice for the nurse to give this mother would be to: 1. Set firm limits and be consistent.

2. Offer the toddler choices.

3. Ignore when the child says “no” and then ask again in five minutes.

4. Tell the child what to do, because she is too young to make decisions and it will only frustrate her.

Answer: 2

Rationale: 1. Setting firm limits and being consistent challenge the toddler’s autonomy and lead to further conflict.

2. The toddler is developing a sense of self, and wants to assert her independence. Giving her choices allows her to experience a sense of autonomy while negating the need for the word “no.”

3. It is inappropriate to ignore inappropriate behavior, and the mother should not begin allowing the child to ignore the mother.

4. Telling the child what to do is not working in the current situation. This advice is essentially telling the mother to do “nothing.”

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 6-4. Apply concepts of communication to the developmental levels of childhood.

8. The nurse caring for a 9-year-old child with extensive burns needs to prepare the child for going to whirlpool therapy for the first time. The most effective response to promote communication with this child would be: 1. “Some of the children I have worked with before have told me that the thing they worried most about was how much it would hurt them.”

2. “Before you leave for whirlpool, I will give you a shot that will relax you, and you probably won’t even remember going downstairs at all.”

3. “I am going to be taking you downstairs to whirlpool, do you have any questions?”

4. “Have you been to the playroom yet? Maybe when you get back from whirlpool we can check it out together.”

Answer: 1

Rationale: 1. “Some of the children I have worked with before have told me that the thing they worried most about was how much it would hurt them” is most likely to encourage the child to discuss his own concerns about the procedure.

2. “Before you leave for whirlpool, I will give you a shot that will relax you, and you probably won’t even remember going downstairs at all” might be confusing and might frighten the child.

3. The child does not know what questions to ask, nor would he voluntarily ask them if he knew.

4. Ignoring the current situation does not allow the child to feel able to open up to the nurse about his fears and concerns.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 6-4. Apply concepts of communication to the developmental levels of childhood.

9. A nurse working with Japanese-American adolescents should be aware of nonverbal communication patterns in their culture. While working with these clients, the nurse should: 1. Shake their hands upon greeting them.

2. Look directly at them while talking with them.

3. Touch them often during the communication to reassure them.

4. Stand very close to them while talking with them.

Answer: 1

Rationale: 1. Handshaking is acceptable in the Japanese culture.

2. Direct eye contact is considered a sign of disrespect 3. Touch is not used very often, especially with casual acquaintances.

4. Distant personal space is the cultural norm.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 6-5. Identify barriers and challenges to communication with the child and family.

10. In order to effectively instruct the parents of a newly diagnosed diabetic child on home care, the most important factor for the nurse to consider while implementing the teaching plan would be: 1. Educational level of the parents.

2. Socioeconomic status of the parents.

3. The level of stress that the parents are experiencing secondary to their child’s diagnosis.

4. Prior medical experience of the parents.

Answer: 3

Rationale: 1. The nurse must consider the educational level, but regardless of this level, the parents will still be unable to learn if their stress is uncontrolled.

2. Socioeconomic status is important to consider, but the level of stress is even more important.

3. All of the above factors are important in designing a teaching plan, but the factor with the greatest impact on the parents’ level of comprehension would be the level of stress that they are experiencing.

4. Prior medical experience is important, but the parent’s stress level will determine their readiness to learn.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment

Learning Outcome: 6-5. Identify barriers and challenges to communication with the child and family.

11. A nurse is working with a child who is a pediatric trauma victim. The nurse is planning nursing interventions to facilitate rapport and effective communication with this child and family. The nursing intervention that is least likely to establish effective, therapeutic communication with the child and family is: 1. Introducing herself to both the child and family.

2. Avoiding the use of medical jargon.

3. Inviting the family out to a movie to decrease its anxiety.

4. Closing the door to the room when speaking with the child or family.

Answer: 3

Rationale:

1. Introducing oneself likely will assist in beginning a therapeutic relationship with the child and family.

2. Avoiding the use of medical jargon will enable the child and family to better understand what is occurring, and is therapeutic.

3. Socializing with clients and family outside of the hospital increases the risk of the nurse’s becoming emotionally overinvolved, blurring her professional boundaries, and decreasing her ability to be therapeutic to the client and family.

4. Providing privacy by closing the door during discussions is a therapeutic communication intervention.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 6-5. Identify barriers and challenges to communication with the child and family.

12. The nurse caring for a Chinese-American child should be aware that which nonverbal communication patterns are acceptable to use when giving information to the child’s father? Select all that apply.

1. Avoiding direct eye contact when listening 2. Handshakes between men only 3. Touch is common with family members and close friends.

4. Distant personal space is preferred.

5. He prefers not to be touched by strangers.

Answer: 1, 4, 5

Rationale: 1. Avoiding direct eye contact, preferring distant personal space, and preferring not to be touched by strangers are all characteristics of nonverbal communication patterns in the Chinese culture.

2. Shaking hands between men only is characteristic of Eastern Indian culture.

3. Touch between family and close friends is more characteristic of the African-American culture.

4. Avoiding direct eye contact, preferring distant personal space, and preferring not to be touched by strangers are all characteristics of nonverbal communication patterns in the Chinese culture.

5. Avoiding direct eye contact, preferring distant personal space, and preferring not to be touched by strangers are all characteristics of nonverbal communication patterns in the Chinese culture.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 6-5. Identify barriers and challenges to communication with the child and family.

13. While assessing an 8-month-old infant, the best strategy for the nurse to use to promote communication with the infant would be to: 1. Speak to the infant in low-pitched, soft tones.

2. Place the infant out of the parents’ view to decrease distraction.

3. Lean over the infant’s face and talk with forceful tones.

4. Use touch, patting and cuddling the infant.

Answer: 4

Rationale: 1. Infants prefer high-pitched, soft tones.

2. Infants do not like to be separated from their parents.

3. It can be scary for an unfamiliar adult to lean over an infant’s face.

4. Infants thrive on touch, and it is a significant form of communication for them.

Cognitive Level: Application

Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 6-6. Apply the nursing process to promote effective communication and establish a therapeutic nurse–child–family relationship.

14. A non–Spanish-speaking nurse is working with a 7-year-old client who is able to speak English, but whose family speaks only Spanish. The nurse needs to give discharge instructions regarding the client’s oral antibiotics. There are no Spanish-speaking interpreters available presently, but one will be able to come in about one hour. The nurse’s most appropriate intervention would be: 1. To give the discharge instructions to the child.

2. To give the discharge instructions to the parents, with the child acting as interpreter.

3. To have the parents wait until an interpreter can be found to translate the discharge instructions.

4. To obtain an English/Spanish translation book and use this to aid in giving discharge instructions to the parents.

Answer: 3

Rationale: 1. A 7-year-old should not be the only person receiving discharge instructions, as this is not legally or developmentally appropriate.

2. A child’s translation might be more self-serving than truthful.

3. Even though the family might have to wait before they can be discharged, the information is too important to rely on anything except a trained interpreter.

4. Using a translation leaves too much room for a potentially inadequate translation by the nurse.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 6-6. Apply the nursing process to promote effective communication and establish a therapeutic nurse–child–family relationship.

15. While the nurse is bathing a 7-year-old child, the child states, “I get so sad when my mom leaves.” The response that ignores the importance of the child’s feelings is: 1. “Could you explain to me what you mean by sad?”

2. “Can you tell me more about how it makes you feel when your mom leaves?”

3. “Your mother has to take care of your brothers and sisters too. She will be back tomorrow.”

4. “I will stay with you tonight while your mother is away.”

Answer: 3

Rationale: 1. Asking the child to explain what is meant lets the child know the feelings experienced are important to the nurse.

2. The nurse’s wanting to know more about the child’s feelings conveys caring for the child, and is therapeutic.

3. This response ignores the importance of the child’s expressed feelings and conveys disinterest in the child.

4. Staying with the child might alleviate some fear of being alone, and might facilitate expression of feelings and establish trust and rapport in the nurse–client relationship.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation

Learning Outcome: 6-6. Apply the nursing process to promote effective communication and establish a therapeutic nurse–child–family relationship.

1. During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be: 1. Soles are flat with prominent fat pads. 2. Positive Babinski’s reflex. 3. Metatarsus varus. 4.

Asymmetric thigh and gluteal folds. Answer: 4 Rationale: 1. Flat soles are normal in newborns.

2. A positive Babinski’s reflex is a normal finding in a newborn.

3. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intrauterine positioning metatarsus and frequently resolves on its own, but approximately 10% of infants with varus also have developmental dysplasia of the hip.

4. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip, requiring follow-up with ultrasound.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment

Learning Outcome: 7-1 Describe the elements of a health history for an infant and children of different ages.

2. A 15-year-old girl is seen for a school physical. Her weight is 121 pounds, and her height is 64 inches. The nurse would calculate her body mass index (BMI) to be ___________.

Answer: 20.7 Rationale:

To calculate the BMI, take the weight in kilograms and divide by the height in meters squared.

To convert weight from pounds to kilograms, divide by 2.2; 121 pounds divided by 2.2 = 55 kg.

To convert the height in inches to meters, multiply by 0.0254; 64 inches multiplied by 0.0254 = 1.63 meters. 1.63 meters squared = 2.66 m2. 55 kg divided by 2.66 meters squared = 20.7 (BMI).

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 7-1Describe the elements of a health history for an infant and children of different ages.

3. The nurse is taking a health history from the family of a 3-year-old child. The statement or question by the nurse that would be most likely to establish rapport and elicit an accurate response from the family is:

1. “Does any member of your family have a history of asthma, heart disease, or diabetes?”

2. “Hello, I would like to talk with you and get some information on you and your child.”

3. “Tell me about the concerns that brought you to the clinic today.”

4. “You will need to fill out these forms; make sure that the information is as complete as possible.”

Answer: 3

Rationale: 1. Giving the family a list of items to answer at once might be confusing to the parents.

2. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed will be even more effective at

establishing rapport and also getting more accurate, pertinent information.

3. Asking the parents to talk about their concerns is an open-ended question, and one that is more likely to establish rapport and an understanding of the parents’ perceptions.

4. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified by the nurse directing the interview.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 7-1Describe the elements of a health history for an infant and children of different ages.

4. During an examination, a nurse asks a 5-year-old child to repeat his address. The nurse most likely is evaluating: 1. Recent memory.

2. Language development.

3. Remote memory.

4. Social skill development.

Answer: 3

Rationale: 1. To evaluate recent memory, the nurse would have the child name something and then ask him to name it again in 10–15 minutes.

2. Listening to how the child talks and to his sentence structure evaluates his language development.

3. Asking children to remember addresses, phone numbers, and dates assesses remote memory development.

4. Assessing how the child interacts with others evaluates social skill development.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance

Nursing Process: Assessment Learning Outcome: 7-2. Describe strategies to gain cooperation of a young child for assessment.

5. A nurse working in the newborn nursery notes that an infant is having frequent episodes of apnea lasting 10–15 seconds without any changes in color or decreases in heart rate. The most appropriate intervention would be to: 1. Call the physician immediately.

2. Continue to observe the infant, and call the physician if the apnea lasts longer than 20 seconds.

3. Suction the infant’s mouth and nares.

4. Turn the infant right side down.

Answer: 2

Rationale: 1. It is unnecessary to inform the physician, as this is normal in a newborn.

2. Apnea lasting less than 20 seconds is a normal finding in newborns as long as there is no associated cyanosis or bradycardia, so continued observation is the most appropriate intervention.

3. There is no indication that suctioning is needed.

4. Turning the baby is not necessary, as apnea lasting 10–15 seconds in a newborn is normal.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 7-3. List five normal variations in pediatric physical findings (such as a Mongolian spot in an infant) observed during a physical assessment.

6. A new mother is worried about a “soft spot” on the top of her newborn infant’s head.

The nurse informs her that this is a normal physical finding called the anterior fontanel. The mother understands further teaching when she states that “It will close on its own when my infant is: 1. “2–3 months of age.” 2. “6–9 months of age.” 3. “12–18 months of age.” 4. “19– 24 months of age.” Answer: 3

Rationale: 1. If the infant’s fontanel closed at 2–3 months of age, the infant’s head size would be too small to accommodate the growing infant’s brain.

2. The infant’s head would be unable to accommodate the growing infant’s brain if the fontanel closed at 6–9 months of age.

3. The anterior fontanel is located at the top of the head, and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at about 12–18 months of age.

4. The infant’s fontanel closes before 19–24 months of age, at 12–18 months.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 7-3. List five normal variations in pediatric physical findings (such as a Mongolian spot in an infant) observed during a physical assessment.

7. The nurse is completing a physical examination of a 4-year-old child. The best position in which to place the child for assessment of the genitalia would be: 1. Frog-leg position.

2. Right side-lying.

3. Supine, with legs at a 50-degree angle.

4. In prone position, with knees drawn up under the body.

Answer: 1

Rationale: 1. Having the child lie supine, flexing her knees and pulling them up to a frog-legged position, allows for accurate assessment of the genitalia, and is the better-tolerated position in the majority of children.

2. There is no reason for a side-lying position, and the child will not tolerate holding the top leg up for long.

3. The child will not tolerate the legs at a 50-degree angle for long.

4. Prone with knees drawn up will allow assessment of the anus, but will not allow for visualization of the vaginal area.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 7-4. Modify physical assessment techniques according to the age and developmental stage of the child.

8. Put the following nursing assessments of a toddler in the best order for the nurse to proceed.

1. Examination of eyes, ears, and throat 2. Auscultation of chest 3. Palpation of abdomen 4. Developmental assessment Answer: 4, 2, 3, 1

Rationale: 4. In examining a toddler, it usually is best to go from least invasive to most invasive examination, in order to build their trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler might view as games, and with which he likely will cooperate.

2. Auscultation usually is less threatening to the toddler than is palpation, especially if the nurse were to use the stethoscope on a parent or a toy.

3. Palpation can be more threatening than is observing or listening, and so should be completed after both.

1. The most uncomfortable, most invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, which should be performed last.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 7-4. Modify physical assessment techniques according to the age and developmental stage of the child.

9. The nurse is assessing a 10-year-old child for cognitive development. The question by the nurse that best determines cognitive development would be: 1. “What books have you read lately?”

2. “What classes are you taking, and what are your grades in them?”

3. “What is your least favorite class?”

4. “What grade are you in?”

Answer: 2

Rationale:

1. Many children have not been encouraged to read books, and while the types of books read would be a good indication of cognitive development, lack of interest in reading would not necessarily indicate poor cognitive development.

2. Asking about what kind of classes the child is taking and also about the grades that the child is receiving in those classes would give the nurse the best indication of how the child is developing cognitively.

3. Determining which classes the child does not enjoy would be helpful, but not the best determinant of poor cognitive development.

4. Grade level is also a good indication of cognitive development, but there could be many different reasons that a child has been held back in school that are not related to cognitive development.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 7-4. Modify physical assessment techniques according to the age and developmental stage of the child.

10. A very concerned 14-year-old boy presents to the clinic because of an enlargement of his left breast. Except for the breast enlargement, the rest of the history and physical was reported as normal. The most appropriate intervention for the nurse to implement next would be to inform the child that: 1. A pediatric endocrine consult is being arranged.

2. The health practitioner is arranging a surgical consult for him.

3. This is a normal finding in adolescent males, and that the breast tissue generally regresses by the time of full sexual maturity.

4. His condition is related to a high-fat diet, and that limiting fat intake usually will resolve the enlargement over a period of a couple of months.

Answer: 3

Rationale:

1. This is a normal finding, and an endocrine consult is not required.

2. There is no reason for a surgical consult, as this is normal for adolescent males.

3. Gynecomastia, or breast enlargement, is a normal finding in adolescent males as they develop toward sexual maturity.

4. The breast enlargement is not related to fat content, but is normal in developing adolescent males.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 7-5. Determine the sexual maturity rating of males and females based upon physical signs of secondary sexual characteristics.

11. A nurse caring for a 9-year-old notices some swelling in the child’s ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation. Due to these physical findings, the nurse would be most concerned with assessing: 1. Skin integrity, especially in the lower extremities.

2. Urine output.

3. Level of consciousness.

4. Range of motion and ankle mobility.

Answer: 2

Rationale: 1. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

2. Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney and cardiac disorders. Decreases in urine output also can indicate compromise in the renal and cardiac systems.

3. Changes in level of consciousness, if present, more than likely would be a later effect in this situation.

4. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 7-6. Analyze findings from the assessment of multiple systems, and recognize signs of a serious health condition.

12. The nurse is caring for an infant diagnosed with “failure to thrive.” The nurse observes the physician taking blood pressures in all four extremities, and recognizes that the congenital cardiac defect suspected is: 1. Tetralogy of Fallot.

2. Pulmonary atresia.

3. Coarctation of the aorta.

4. Ventricular septal defect.

Answer: 3

Rationale: 1. There are minimal differences between upper and lower blood pressure readings in tetralogy of Fallot.

2. There are minimal differences between upper and lower blood pressure readings in pulmonary atresia.

3. Normally, blood pressures in the lower extremities are the same or higher than upperextremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes

decreased blood flow to the lower extremities, and so lower extremity blood pressure readings are significantly lower than upper-extremity readings.

4. There are minimal differences between upper and lower blood pressure readings in ventricular septal defect.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 7-6. Analyze findings from the assessment of multiple systems, and recognize signs of a serious health condition.

13. A 7-year-old presents to the clinic with an exacerbation of asthma symptoms. On physical exam, the nurse would expect which of the following findings? Select all that apply.

1. Wheezing 2. Increased tactile fremitus 3. Decreased vocal resonance 4. Decreased tactile fremitus 5. Bronchophony Answer: 1, 3, 4 Rationale:

1. Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations.

2. An increase in tactile fremitus is indicative of pneumonia.

3. Asthma causes a decreased vocal resonance, as edema makes it more difficult for the sound to project.

4. The air trapping in the lungs that occurs with asthma causes a decrease in the sensation of vibrations or a decreased tactile fremitus.

5. Bronchophony is an increase in the intensity and clarity of transmitted sounds that also is indicative of pneumonia.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 7-6. Analyze findings from the assessment of multiple systems, and recognize signs of a serious health condition.

14. While inspecting a 5-year-old child’s ears, the nurse notes that the right pinna protrudes outward, and that there is a mass behind the right ear. In light of these findings, the vital sign parameter that the nurse would be most concerned with would be: 1. Temperature.

2. Heart rate.

3. Respirations.

4. Blood pressure.

Answer: 1

Rationale: 1. Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this.

2. There also could be changes in other vital sign parameters, but heart rate, respiratory rate, and blood pressure would not be specific for the presence of infection.

3. There also could be changes in other vital sign parameters, but heart rate, respiratory rate, and blood pressure would not be specific for the presence of infection.

4. There also could be changes in other vital sign parameters, but heart rate, respiratory rate, and blood pressure would not be specific for the presence of infection.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment

Learning Outcome: 7-6. Analyze findings from the assessment of multiple systems, and recognize signs of a serious health condition.

15. While assessing a 10-month-old African-American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would the nurse suspect as having an ongoing disease process?

1. Cardiac 2. Respiratory 3. Gastrointestinal 4. Genitourinary Answer: 3

Rationale: 1. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

2. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

3. This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system.

4. Tenting of the skin and dry mucous membranes could be signs of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 7-6. Analyze findings from the assessment of multiple systems, and recognize signs of a serious health condition.

1. While teaching the parents of a newborn about infant care and feeding, the nurse instructs the parents to:

1. Delay supplemental foods until the infant is 4–6 months old.

2. Delay supplemental foods until the infant reaches 15 pounds or greater.

3. Begin diluted fruit juice at 2 months of age, but wait 3–5 days before trying a new food.

4. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age.

Answer: 1 Rationale: 1. Age 4–6 months is the optimal age to begin supplemental feedings. Earlier feeding of nonformula foods is not needed by the infant, and does not promote sleep.

2. Earlier feeding of nonformula foods, regardless of the infant’s weight, is more likely to cause the development of food allergies.

3. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age, as they lack the digestive enzymes to take in and metabolize many food products.

4. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age, as they lack the digestive enzymes to take in and metabolize many food products.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-1 Discuss major nutritional concepts pertaining to the growth and development of children.

2. A nurse is talking to the mother of an exclusively breastfed African-American 3-month-old infant who was born in late fall. The nurse would want to make sure that this child is receiving:

1. Iron.

2. Vitamin D. 3. Fluoride.

4. Calcium.

Answer: 2 Rationale: 1. An infant’s iron stores are usually adequate until about 4–6 months of age.

2. This infant will have limited exposure to sunlight, and thus vitamin D, because of the infant’s dark skin and decreased sun exposure in the fall and winter months.

3. Fluoride supplementation, if needed, does not begin until the child is approximately 6 months old.

4. The infant should be receiving sufficient amounts of calcium from breast milk.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 8-1 Discuss major nutritional concepts pertaining to the growth and development of children.

3. While teaching parents of a newborn about normal growth and development, the nurse

informs them that their child’s weight should: 1. Triple by 6 months of age.

2. Double by 1 year of age.

3. Double by 5 months of age.

4. Triple by 9 months of age.

Answer: 3 Rationale: 1. It would be abnormal to have tripled in weight by 6 months of age.

2. It would be abnormal for the infant’s weight only to have doubled by 1 year of age.

3. Normal weight gain for an infant would be to have doubled in weight by 5 months of age.

4. It would be abnormal to have tripled in weight by 9 months of age.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 8-1Discuss major nutritional concepts pertaining to the growth and development of children.

4. The nurse is teaching the parents of a 4-month-old infant about good feeding habits.

The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle, as this is most likely to increase the incidence of both dental caries and:

1. Otitis media.

2. Aspiration.

3. Malocclusion problems.

4. Sleeping disorders.

Answer: 1 Rationale: 1. It has been shown in numerous studies that allowing an infant to fall asleep with a bottle in her mouth causes pooling of the formula in the mouth, which increases the risk of both dental caries and otitis media.

2. There have been limited data to date showing a positive correlation to bottle propping and increased risk of aspiration, malocclusions, and sleeping disorders.

3. There have been limited data to date showing a positive correlation to bottle propping and increased risk of aspiration, malocclusions, and sleeping disorders.

4. There have been limited data to date showing a positive correlation to bottle propping and increased risk of aspiration, malocclusions, and sleeping disorders.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-1 Discuss major nutritional concepts pertaining to the growth and development of children.

5. The mother of a premature infant born at 32 weeks’ gestation expresses the desire to breastfeed her child. An appropriate suggestion by the nurse would be: 1. “Mothers who cannot directly breastfeed should talk with and stroke their infants during

gavage feedings, as this can help facilitate milk letdown.”

2. “The letdown reflex is best initiated by having the baby suck at the breast.”

3. “Pumping should be done no more than three times daily, making sure to empty each breast completely.”

4. ”You should begin pumping by six hours postpartum to ensure adequate milk production.”

Answer: 4

Rationale: 1. Just because a newborn is premature does not preclude the mother from breastfeeding.

The mother can breastfeed unless some other issue is present.

2. Pumping the breast can facilitate milk letdown.

3. Breast pumping should be done at least five or more times per day to ensure an adequate supply of milk.

4. It is best for the mother to initiate the letdown reflex by stimulating the breast prior to feeding so that the infant will not have to suck as hard, which can burn unnecessary calories. The sooner the mother can begin breast pumping postpartum, the more likely she is to produce an adequate milk supply.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-2. Describe and plan nursing interventions to meet nutritional needs for all age groups from preterm infants through adolescents.

6. The mother of a 2-year-old is concerned because her child does not seem interested in eating.

The child is drinking about 5–6 cups of whole milk per day and 1 cup of fruit juice. When the

weight-to-height percentile is calculated, the child is in the 90–95th percentile. What would be the best advice for the nurse to give this mom?

1. Eliminate the fruit juice from the child’s diet.

2. Offer healthy snacks, presented in a creative manner, and let the child choose what she wants to eat without pressure from the parents.

3. Change from whole milk to 2% milk and decrease milk consumption to 3–4 cups per day and the fruit juice to one-half cup per day, offering water if the child is still thirsty in between.

4. Make sure that the child is getting adequate opportunities for exercise, as this will increase her appetite and help lower her weight-to-height percentile.

Answer: 3

Rationale: 1. Eliminating the fruit juice is appropriate, but does not address the excessive milk consumption.

2. If the child is not hungry, the child will not eat, regardless of the snacks presented.

3. Toddlers require a maximum of about one liter of milk per day. This toddler is consuming most of her calories from the milk, and thus is not hungry. The high fat content of the milk and the high sugar content of the fruit juice also are contributing to the child’s higher weight-toheight percentile. Decreasing the amount and fat content of the milk and decreasing the intake of fruit juice will decrease calories and make the child hungry for other foods.

4. Increasing exercise is appropriate, but does not address the problem of excessive milk consumption.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-2. Describe and plan nursing interventions to meet nutritional needs for all age groups from preterm infants through adolescents.

7. A vegetarian adolescent has been placed on iron supplementation secondary to a diagnosis of iron-deficiency anemia. To increase the absorption of iron, the nurse would instruct the teen to take the supplement with:

1. Black or green tea.

2. Orange juice.

3. Milk.

4. Tomato juice.

Answer: 2 Rationale: 1. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

2. Acidity increases absorption of iron.

3. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

4. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 8-2. Describe and plan nursing interventions to meet nutritional needs for all age groups from preterm infants through adolescents.

8. The nurse has been completing a nutritional assessment with an 18-month-old.

The comment by the parent that would prompt the nurse to provide the parent with further education is:

1. “We allow our child to drink only pasteurized apple cider.”

2. “We take the meat out of the freezer and then allow it to thaw on the counter for 2–3 hours before cooking it thoroughly.”

3. “We always wash our hands well before any food preparation.”

4. “We use separate utensils for preparing raw meat and for preparing fruits, vegetables, and other foods.”

Answer: 2

Rationale: 1. Washing hands, using separate utensils, and not serving unpasteurized apple cider help to prevent infection with food-borne pathogens.

2. Allowing meat to sit out on a counter can cause the bacteria counts to increase quickly, and cooking the meat might not effectively destroy all of the bacteria. Frozen meat should be thawed in the refrigerator prior to cooking.

3. Washing hands, using separate utensils, and not serving unpasteurized apple cider help to prevent infection with food-borne pathogens.

4. Washing hands, using separate utensils, and not serving unpasteurized apple cider help to prevent infection with food-borne pathogens.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 83. Integrate methods of nutritional assessment into care for children and adolescents.

9. During a 4-month-old’s well-child checkup, the nurse discusses introduction of solid foods into the infant’s diet and concerns for foods commonly associated with food allergies.

Therefore, the parents are instructed to delay until after 1 year of age the introduction of:

1. Strawberries, eggs, and wheat.

2. Honey, tomatoes, and spinach.

3. Carrots, beets, and spinach.

4. Squash, pork, and tomatoes.

Answer: 1 Rationale: 1. Strawberries, eggs, and wheat, along with corn, fish, and nut products, are foods that have commonly been associated with food allergies.

2. Honey can contain botulism spores, which cannot be detoxified by the infant younger than 1 year old, but does not cause an allergic reaction.

3. Carrots, beets, and spinach contain nitrates, and should not be given before 4 months of age.

4. Squash and tomatoes are okay to try after an infant is 4–6 months old, but should be given one at a time, and 3–5 days after starting a new food. Pork can be tried after the infant is 8–10 months old, as meats are harder to digest, and have a high protein load.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-4. Discuss common nutritional concerns of children growing up in developed countries.

10. While teaching a health promotion class to a group of parents of children in a Head Start class, the nurse informs the parents that the most common preventable chronic infectious disease in U.S. children is:

1. Hepatitis A. 2. Dental decay.

3. Human immunodeficiency virus (HIV) 4. Herpes.

Answer: 2 Rationale: 1. Hepatitis A, HIV, and herpes are not the most common preventable chronic infectious diseases in the U.S. 2. By 2–4 years of age, 17% of U.S. children have already had dental decay, and by the age of 8, 52% of children have experienced dental decay, making this the most common preventable chronic infectious disease in U.S. children.

3. Hepatitis A, HIV, and herpes are not the most common preventable chronic infectious diseases in the U.S. 4. Hepatitis A, HIV, and herpes are not the most common preventable chronic infectious diseases in the U.S. Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-4. Discuss common nutritional concerns of children growing up in developed countries.

11. The parents of a 2½-year-old are concerned about their child’s finicky eating habits. While counseling the parents, the nurse would accurately make which statements? Select all that apply.

1. “The child is experiencing physiologic anorexia, which is normal for this age group.”

2. “A general guideline for food quantity at a meal is one-quarter cup of each food per year of age.”

3. “It is more appropriate to assess a toddler’s nutritional demands over a 1-week period rather than a 24-hour one.”

4. “Nutritious foods should be made available at all times of the day, so that the child is able to ‘graze’ whenever he is hungry.”

5. “The toddler should drink 16–24 ounces of milk daily.”

Answer: 1, 3, 5

Rationale: 1. Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and is a very normal finding at this age.

2. The correct general guideline for food quantity is one tablespoon of each food per year of age.

3. It is not unusual for toddlers to have food jags where they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day.

4. Food should be offered only at meal and snack times.

5. 2–3 cups of milk per day are sufficient for a toddler, and more than that can decrease his desire for other foods and lead to dietary deficiencies. Children should sit at the table while eating to encourage socialization skills.

Cognitive Level: Application Client Need: Health Promotion and Maintenance

Nursing Process: Implementation Learning Outcome: 8-4. Discuss common nutritional concerns of children growing up in developed countries.

12. A 6-year-old recently diagnosed with asthma also has a peanut allergy. The nurse instructs the family not only to avoid peanuts, but also to check food label ingredients carefully for peanut products and to make sure dishes and utensils are adequately washed prior to food preparation. The mother asks why this is specific for her child. The nurse should reply that in comparison with other children, this child has a higher risk for:

1. Urticaria.

2. Diarrhea.

3. Anaphylaxis.

4. Headache.

Answer: 3 Rationale: 1. Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

2. Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

3. The child who also has asthma is at greatest risk for death secondary to anaphylaxis caused by a food allergy.

4. Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 8-5. Apply the nursing process to care for children or adolescents with feeding and eating disorders.

13. During a well-child physical, a 16-year-old girl has a normal history and physical except for an excessive amount of tooth enamel erosion, a greater-than-normal number of filled cavities, and calluses on the back of her hand. Her body mass index is in the 50–75th percentile for her age. The nurse would be most concerned about:

1. Anorexia nervosa.

2. Kwashiorkor.

3. Bulimia nervosa.

4. Marasmus.

Answer: 3 Rationale: 1. Anorexia nervosa is an eating disorder where adolescents literally starve themselves to prevent weight gain, also exercising excessively and using laxatives and diuretics to lose weight.

Anorexia usually manifests as extreme weight loss and an obsession with food.

2. Kwashiorkor is a protein deficiency, usually from malnutrition, that manifests as generalized edema.

3. The erosion of the tooth enamel, dental caries, and calluses on the back of her hand all most

likely are due to frequent vomiting of gastric acids, which is common with this disorder as part of a “binge–purge” cycle.

4. Marasmus is a lack of energy-producing calories that can be seen in anorexia, and causes emaciation, decreased energy levels, and retarded development.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 8-5. Apply the nursing process to care for children or adolescents with feeding and eating disorders.

14. A 6-year-old child has been newly diagnosed with cystic fibrosis. During discharge teaching, the nurse is instructing the parents on nutritional requirements specifically related to the child’s decreased ability to absorb fats. The nurse teaches the family that the child will need supplementation with vitamins that are fat-soluble, such as:

1. Riboflavin.

2. Vitamin K. 3. Thiamin.

4. Vitamin B12.

Answer: 2

Rationale: 1. Riboflavin, vitamin B12, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

2. Vitamin K is fat-soluble, as are A, D, and E. 3. Riboflavin, vitamin B12, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

4. Riboflavin, vitamin B12, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8-6. Describe the nurse’s role when children need specialized nutritional support due to illness or lifestyle.

1. Which of these nursing activities can be classified as those which promote health promotion and maintenance? Select all that apply.

1. Administration of the flu vaccine for infants from 6 to 23 months of age 2. Daily feeding schedules for infants 3. Instruction to adolescents on how to use dental floss 4. Treatment for a child with a diagnosis of acute otitis media 5. Teaching parents how to perform pulmonary drainage and cupping on their ill child.

Answer: 1, 2, 3 Rationale: 1. Administration of flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health promotion and/or maintenance topics.

2. Administration of flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health promotion and/or maintenance topics.

3. Administration of flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health promotion and/or maintenance topics.

4. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and maintenance, since it is an acute illness.

5. Teaching parents how to perform pulmonary drainage and cupping on their ill child is not considered health promotion and maintenance, as it is treating an acute illness.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance

Nursing Process: Implementation Learning Outcome: 9-1. Define health promotion and maintenance.

2. Student nurses are observing in the pediatric well-child clinic. The students observe that prior to administering an immunization to a child, a nurse explains the reason for the immunization series to the mother. While discussing the incident in post-conference, the students report that this activity was:

1. Health assessment.

2. Health promotion.

3. Health maintenance.

4. Health screening.

Answer: 2 Rationale: 1. A health assessment would be completed to determine what immunizations were needed.

2. The explanation to the mother by the nurse provides an understanding of the immunization series to the mother, and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion.

3. Health maintenance is exemplified by the actual administration of the immunization.

4. The health screening involves looking at the immunization record to determine which immunizations are needed.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-1. Define health promotion and maintenance.

3. A mother says to a nurse, “I am so concerned about my 14-year-old daughter, since she has been caught stealing small articles of clothing and jewelry from stores on several occasions.”

The nurse begins a discussion on strategies for improving ethical behavior. This plan of care is part of:

1. Health maintenance.

2. Health promotion.

3. Behavioral discipline.

4. Moral conditioning.

Answer: 2 Rationale: 1. Since there is a report of unethical behaviors in this scenario, the nurse would not be using health maintenance strategies, which would not be problem-focused. Health maintenance would not involve a discussion on ethical behaviors.

2. Health promotion includes strategies designed to improve the state of wellness.

3. A discussion on strategies for improving ethical behavior might include consequences (discipline), but there is no indication in the stem that the nurse is advocating discipline.

4. Moral conditioning is not an applicable choice.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-1. Define health promotion and maintenance.

4. Which of the following is not a benefit of the pediatric health care home?

1. Comprehensive and continuous care for the child.

2. Preventive anticipatory guidance based on the family’s protective factors and risks.

3. Provision of specialty care visits as needed.

4. Increase in emergency room visits for needed care.

Rationale: 1. A benefit of the pediatric health care home is the provision of comprehensive, compassionate and continuous care for the child.

2. The healthcare home includes preventive health care visits.

3. The healthcare home includes insuring visits to specialty clinics as needed.

4. Emergency room visits should be less when a child has a pediatric health care home.

Cognitive Level: Knowledge Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 9-2 Describe the importance of a medical home, also known as a pediatric healthcare home.

5. A mother brings a child to the pediatric office for a sick visit. The nurse should: 1. Focus exclusively on the reported illness.

2. Review health promotion and maintenance activities.

3. Ask the mother to leave the room after obtaining the history.

4. Obtain a comprehensive history, including sociodemographic data.

Answer: 2

Rationale: 1. Focusing exclusively on the reported illness(es) ignores the opportunity to use health promotion strategies.

2. A nurse should use every opportunity and office visit to review health promotion and maintenance activities.

3. There are not enough data in this scenario to determine whether the mother should be asked to leave the room.

4. There is not enough information to indicate that a comprehensive history should be taken at this visit.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-3. Describe how health promotion and maintenance are addressed by partnering with families during health supervision visits.

6. Which of these strategies would be most effective for a “teachable moment” for the parents of a 6-year-old child during a routine office visit?

1. Select one topic and present a brief amount of information on the topic.

2. Review all 6-year-old anticipatory guidelines with the parents.

3. Review 7-year-old anticipatory guidelines with the parents.

4. Discuss signs of malnutrition with the parents.

Answer: 1 Rationale: 1. Children and families often learn best when presented with small bits of information.

2. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate.

3. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate.

4. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome: 9-3. Describe how health promotion and maintenance are addressed by partnering with families during health supervision visits.

7. Which nursing assessment activities should be included for the child and family at each health supervision visit? Select all that apply.

1. Interview to obtain an updated health history

2. Performing an age-appropriate development assessment

3. Monitoring parents’ ability to pay for services 4. Performing age-appropriate screening examinations 5. Physical assessment for genetic abnormalities Answer: 1, 2, 4 Rationale: 1. The interview, the developmental assessment, and age-appropriate screenings all are included in the nursing assessment of a child and family during each health supervision visit.

2. The interview, the developmental assessment, and age-appropriate screenings all are included in the nursing assessment of a child and family during each health supervision visit.

3. A nurse would not assess the parents’ financial status at each health supervision visit.

4. The interview, the developmental assessment, and age-appropriate screenings all are included in the nursing assessment of a child and family during each health supervision visit.

5. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-4. Describe the components of a health supervision visit.

8. A nurse is helping the parents of 2-year-old twins cope with the daily demands of life in an active household. Which of these strategies should the nurse use?

1. Health maintenance 2. Health promotion 3. Partner development 4. Health supervision

Answer: 2 Rationale: 1. The definition of health maintenance has nothing to do with the daily demands of a household.

This is health promotion.

2. In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping.

3. Partner development is simply a distractor, and should be ignored.

4. Health supervision is a strategy more useful for management of chronic illnesses and on overall preventative behaviors.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-5. Explore the nurse’s role in providing health promotion and maintenance for children of different ages in a variety of settings.

9. Which of these questions is most important for a nurse to ask an adolescent whose weight is at the 5th percentile?

1. “Do you eat the school lunches?”

2. “Do you have any concerns about your weight?”

3. “Do you eat fruits and vegetables, and drink milk?”

4. “How many meals do you eat each day?”

Answer: 2 Rationale: 1. Asking about school lunches does not directly address the adolescent’s being underweight.

2. The only question that addresses the adolescent’s weight, which is below the expected norm, is “Do you have any concerns about your weight?”

3. Whether the child eats fruits and vegetables, and how many meals are eaten each day, should be used to obtain a nutritional history, but do not address the underweight status of the adolescent.

4. Whether the child eats fruits and vegetables, and how many meals are eaten each day, should be used to obtain a nutritional history, but do not address the underweight status of the adolescent.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 9-5. Explore the nurse’s role in providing health promotion and maintenance for children of different ages in a variety of settings.

10. A pediatric nurse who is employed in a busy ambulatory clinic setting is informed by the nurse manager that average nursing time allocated for each child and family is being reduced to 10 minutes to manage the clinic more efficiently. The nursing activities must include a nursing assessment and discussion on anticipatory guidance. Which of these strategies should the nurse utilize in the plan of care delivery?

1. Attempt to complete the assessment and education in 10 minutes, but extend the time whenever the nurse deems necessary.

2. Plan to do the anticipatory guidance first, since either the nurse practitioner or the physician can perform assessment of the child.

3. Ask each parent to complain to the nurse manager that there is not adequate time to talk with the nurse at each visit.

4. Focus anticipatory guidance strategies on topics in which the parent or child has expressed interest.

Answer: 4

Rationale: 1. Limiting assessment and education to 10 minutes does not give either activity ample time.

2. Performing anticipatory guidance prior to history taking does not follow the nursing process.

3. Suggesting that parents complain to a nurse manager might be destructive to the needs of the children and parents, and might adversely affect the operation of the nursing unit 4. With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will benefit the parent and child most during that office visit.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation

Learning Outcome: 9-5. Explore the nurse’s role in providing health promotion and maintenance for children of different ages in a variety of settings.

11. The nurse at an outpatient clinic is sitting with the parents while their adolescent goes for a test. The parents are complaining about their child’s behavior. The nursing statement to a parent that fosters family-centered communication is:

1. “I agree with you, discipline is an important part of parenting.”

2. “I know just how you feel. I had the same experience with my children.”

3. “You are so right. Adolescents function in the me-first mode all the time.”

4. “Tell me how you feel when your adolescent is aggressive with you.”

Answer: 4 Rationale: This statement is a blocking statement, and would not foster family-centered communication.

2. This statement is a blocking statement, and would not foster family-centered communication. 3. This statement is a blocking statement, and would not foster familycentered communication. 4. Using an open-ended question allows the parents to discuss a family concern.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-6. Describe the general observations of children and their families as they come to the pediatric health care home for health supervision visits.

12. A parent says to a nurse, “How do you know when my child needs these screening tests the doctor just mentioned?” Which response should the nurse make to the parent?

1. “Screening tests are administered at the ages when a child is most likely to develop a condition.”

2. “Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first two years of life.”

3. “Screening tests are most often done when the doctor suspects something is wrong with the child.”

4. “Screening tests are done at each office visit.”

Answer: 1 Rationale: 1. This response provides a definition for screening tests.

2. Abnormal newborn screening tests require immediate follow-up.

3. Screening tests are done to detect the possibility of problems, not when a problem is suspected.

4. Screening tests are not done at each office visit.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-6. Describe the general observations of children and their families as they come to the pediatric health care home for health supervision visits.

13. The mother of a 4-year-old child reports daily episodes of encopresis, and that many of the children at the preschool make fun of her child. What is the best strategy for the nurse to use as an advocate?

1. Discuss with the mother ways to conceal the child’s diapers.

2. Encourage the mother to dress the child in dark pants.

3. Tell the mother to keep the child at home until potty-trained.

4. Call the school nurse and teacher while the parent is in the office to discuss the situation and identify possible solutions.

Answer: 4 Rationale: 1. This choice does not directly deal with the issue of the child’s being teased by the other children, or with identifying solutions. This choice merely deals with hiding the problem.

2. This choice does not directly deal with the issue of the child’s being teased by the other children, or with identifying solutions. This choice merely deals with hiding the problem.

3. This choice does not directly deal with the issue of the child’s being teased by the other children, or with identifying solutions. It is not appropriate to have this child miss school until this problem is dealt with.

4. Devising the plan to call the school nurse and teacher is part of the role of the nurse advocate.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-7. Describe the areas of assessment and intervention for health supervision visits—growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and

social relationships, disease prevention strategies, and injury prevention strategies.

14. The mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. The appropriate nursing response to the mother would be to say: 1. “What do you usually do or say during a temper tantrum?”

2. “Let’s ignore this behavior. It will stop sooner.”

3. “Pick up and cuddle your child now, please.”

4. “This is definitely a temper tantrum. I know exactly what you are feeling right now.”

Answer: 1 Rationale: 1. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management, and will lead the nurse to assist the mother in making a plan of care for temper tantrums.

2. Ignoring the behavior, instructing the mother to cuddle the child, and sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem-solve for temper tantrums.

3. Ignoring the behavior, instructing the mother to cuddle the child, and sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem-solve for temper tantrums.

4. Ignoring the behavior, instructing the mother to cuddle the child, and sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem-solve for temper tantrums.

Cognitive Level: Analysis

Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-7. Describe the areas of assessment and intervention for health supervision visits—growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relationships, disease prevention strategies, and injury prevention strategies.

15. A nurse says to the mother of a 6-month-old infant, “Does the baby sit without assistance, and is the baby crawling?” Which process is the nurse using in this interaction?

1. Health promotion 2. Health maintenance 3. Disease surveillance 4. Developmental surveillance Answer: 4 Rationale: 1. While health promotion and maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers health promotion and health maintenance are incorrect.

2. While health promotion and maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers health promotion and health maintenance are incorrect.

3. The questions asked in the stem are not classified as disease surveillance questions.

4. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 9-7. Describe the areas of assessment and intervention for health supervision visits—growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relationships, disease prevention strategies, and injury prevention strategies.

16. A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child, and notes that the parents often miss routine health care visits, and that the child has not received the second measles, mumps, and rubella (MMR) vaccine. The nurse should:

1. Speak firmly with the parents about the importance of being compliant.

2. Notify the physician that the child’s immunizations are no longer up to date.

3. Call the parents and encourage them to bring the child for recommended care.

4. Plan to discuss the principles of health supervision at the next scheduled visit.

Answer: 3 Rationale: 1. Speaking firmly with the parents about compliance will alienate the parents at this time.

2. The nurse is responsible for reviewing the health supervision of the child, there is not reason to abdicate this to another health professional.

3. Partnering with the parents and encouraging the parents to follow health supervision guidelines is the best strategy to use.

4. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed health care for the child in this example.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 9-8. Apply the nursing process to assess, diagnose, establish goals, intervene, and evaluate care related to health promotion and maintenance of children and adolescents in a variety of settings.

1. During the visit to the pediatric office, a nurse observes the mother frequently looking at the infant and massaging the infant. From these observations, the nurse’s conclusion should be: 1. Positive maternal–infant attachment.

2. Inadequate; more data are needed to assess the mother–infant relationship.

3. That the mother might be overwhelmed by the demands of infant care.

4. That the mother is trying to show the nurse that she can be affectionate to the infant.

Answer: 1

Rationale: 1. These behaviors are characteristic of a positive maternal–infant attachment.

2. There is enough information to determine the presence of positive maternal–infant attachment.

3. There is no information indicating the mother might be overwhelmed.

4. The mother might be trying to show the affection, but the more global answer is that the massaging and looking at the infant indicate positive maternal–infant attachment.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation

Learning Outcome: 10-1. Verbalize the important link between prenatal care and health promotion and maintenance of the family and newborn.

2. A nurse in the newborn unit should perform which activities during the first 48 hours of life?

Select all that apply.

1. Monitor feeding behaviors.

2. Perform a hearing screening.

3. Perform a heel stick to obtain blood for the newborn screen.

4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids.

5. Administer a folic acid injection to the infant to prevent bleeding.

Answer: 1, 2, 3 Rationale: 1. The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed.

2. A hearing screening is performed on all newborn infants prior to discharge.

3. The newborn screen is performed prior to infant discharge from the newborn unit.

4. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids.

5. Vitamin K, not folic acid, is administered.

Cognitive Level: Application Client Need: Health Promotion and Disease Prevention Nursing Process: Implementation Learning Outcome: 10-2. Identify the major health concerns regarding the newborn.

3. A newborn is discharged from the hospital on day two of life. The mother reports that two siblings were diagnosed with hyperbilirubinemia on day eight of life. The nurse will schedule the follow-up home visit for this newborn on day:

1. Five.

2. Three.

3. Eight.

4. Nine.

Answer: 2

Rationale: 1. Waiting until day five, eight, or nine after discharge from the hospital is incorrect, since the early signs of hyperbilirubinemia could be missed if the nurse waits this length of time to evaluate the infant.

2. The infant is at risk for hyperbilirubinemia. The mother might not have recognized the signs of hyperbilirubinemia in the early stage; therefore, the nurse should make the first home visit at day three of life.

3. Waiting until day five, eight, or nine after discharge from the hospital is incorrect, since the early signs of hyperbilirubinemia could be missed if the nurse waits this length of time to evaluate the infant.

4. Waiting until day five, eight, or nine after discharge from the hospital is incorrect, since the early signs of hyperbilirubinemia could be missed if the nurse waits this length of time to evaluate the infant.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 10-2. Identify the major health concerns regarding the newborn.

4. The nurse is teaching a new mother developmental expectations. Which of these activities should

the nurse expect an infant to do within the first month of life? Select all that apply.

1. Bring hands to eyes and mouth.

2. Move head from side to side when lying on abdomen.

3. Keep hands in a relaxed position.

4. Attempt to lift head when prone.

5. Roll over from back to abdomen.

Answer: 1, 2, 4

Rationale: 1. Infants at 1 month of age can bring their hands to eyes and mouth, move their head from side to side when lying on their abdomen, and attempt to lift their head when prone.

2. Infants at 1 month of age can bring their hands to eyes and mouth, move their head from side to side when lying on their abdomen, and attempt to lift their head when prone.

3. Infants’ hands are kept in tight-fist position, and the infant cannot roll over until 4 months of age.

4. Infants at 1 month of age can bring their hands to eyes and mouth, move their head from side to side when lying on their abdomen, and attempt to lift their head when prone.

5. Infants’ hands are kept in tight-fist position, and the infant cannot roll over until 4 months of age.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 10-3. Describe physical and developmental milestones expected by the end of the first month of life.

5. A mother who is bottle-feeding her newborn requests to be discharged 24 hours post-delivery, since the mother also has twin 2-year-olds at home. The nurse should schedule the office visit for the newborn on which of these days?

1. Within 48 hours of discharge 2. Within 1 week of discharge 3. Within 2 weeks of discharge 4. When the infant is 1 month old Answer: 1

Rationale: 1. Newborns discharged before 48 hours old should be seen within 48 hours of discharge.

2. Waiting 1 or 2 weeks after discharge of a 24-hour-old increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice and failure to gain weight).

3. Waiting 1 or 2 weeks after discharge of a 24-hour-old increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice and failure to gain weight).

4. Waiting 1 month is too long for any infant who is discharged at 24 hours old.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing LearningProcess: Outcome:Implementation 10-4. Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of newborns.

6. The nurse in the newborn nursery is admitting a neonate. In order to determine the health and development of the newborn, the nurse will assess: (Select all that apply.)

1. Head circumference.

2. Body length.

3. Weight.

4. Length of pregnancy.

5. Body fat determination.

Answer: 1, 2, 3, 4

Rationale: 1. The nurse should assess all of these parameters to determine the health of the newborn.

2. The nurse should assess all of these parameters to determine the health of the newborn.

3. The nurse should assess all of these parameters to determine the health of the newborn.

4. The nurse should assess all of these parameters to determine the health of the newborn.

5. Body fat determination is not a measure that is used during the newborn assessment.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 10-4. Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of newborns.

7. An infant weighs 9 pounds, 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age?

1. 7 pounds, 12 ounces 2. 8 pounds, 2 ounces 3. 8 pounds, 12 ounces 4. 9 pounds

Answer: 2 Rationale: 1. 7 pounds, 12 ounces would be too much weight loss for this infant.

2. In the first week of life, most infants lose about one tenth of their birth weight; therefore, this infant’s weight should be 8 pounds, 2 ounces at 7 days of age.

3. 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth.

4. An infant would not be expected to lose only 3 ounces during the first week of life.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 10-4. Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of newborns.

8. A nurse observes an infant in a crib lying still, without facial movements, except for occasional sucking movements. At this time, the nurse will avoid: 1. Assessing heart and respiratory rate.

2. Skin assessment.

3. Repositioning the head of the infant.

4. Attempts to feed the infant.

Answer: 4

Rationale: 1. There is no contraindication to assessing the heart and respiratory rate.

2. There is no contraindication to assessing the infant’s skin.

3. Repositioning the head of the infant is acceptable to do while the infant is in a deep sleep.

4. This infant is in a quiet, deep sleep. Attempts to feed the infant should not be made until the infant is in a lighter sleeping pattern, since the infant will be unresponsive to attempts at arousal, and might be at risk for aspiration.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 10-4. Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of newborns.

9. The 4-year-old sibling of a new baby comes in with the parents for the newborn’s first health supervision visit and asks multiple questions about the baby and what the nurse is doing. Which statement is most indicative of therapeutic communication with this child?

1. “I know you must have lots of questions. Your parents will be able to talk to you about all of it later.”

2. “I am making sure your baby brother is doing okay. Would you like to help me look him over?”

3. “Your parents brought your brother in to us to make sure he is doing okay, so can you ask your questions later?”

4. “I think your questions are distracting me; can you read this book for me while I finish this exam?”

Answer: 2 Rationale: 1. It would be best for the sibling if the nurse could talk to the 4-year-old while the exam is occurring instead of putting the task off on the parents. This involves the child in the new baby’s care.

2. Asking the child to help the nurse gives the 4-year-old a sense of importance and involvement with the new baby.

3. The nurse needs to include the sibling in the experience to make sure she does not feel left out or resentful of the new baby’s needs.

4. This statement would hurt the sibling’s feelings, and is not therapeutic for this family.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome: 10-5. Apply therapeutic communication skills with the newborn and family during health supervision visits.

10. In planning care for clients in a newborn clinic, the nurse’s priority activity during the first clinic visit will be: 1. Providing pamphlets to reinforce information provided at the visit.

2. Assessing the newborn and family interactions.

3. Modeling infant-nurturing behaviors.

4. Informing the parents of the infant gains in height and weight.

Answer: 2 Rationale: 1. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs.

2. The first step in the nursing process is assessment; therefore, the nurse should assess the

interactions of the parents with the newborn.

3. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit.

4. While parents are informed of the infant’s gains in height and weight, this activity does not take priority.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 10-6. Intervene with newborns and their families to integrate activities to promote health and to prevent disease and injury.

11. An infant is born at 28 weeks’ gestational age. A nurse should inform the parents that the infant should be expected to reach developmental milestones about how many weeks later than would a full-term infant?

1. 6 2. 8 3. 12 4. 16 Answer: 3 Rationale:

1. This is only half the time needed to adjust to the corrected age.

2. This does not apply to the corrected age based on the infant’s being 12 weeks early.

3. Preterm infants are evaluated according to the “corrected age.” This infant, born at 28 weeks’ gestational age, is 12 weeks premature. Therefore, the infant should be expected to reach developmental milestones about 12 weeks later than would an infant who was born full-term.

4. This is more than the correction needed to determine the corrected age for this infant.

Cognitive Level: Application Client Need: Health Promotion and Maintenance

Nursing Process: Implementation Learning Outcome: 10-6. Intervene with newborns and their families to integrate activities to promote health and to prevent disease and injury.

12. The recommendation for an infant’s sleeping position is now “back to sleep.” Which nursing intervention is needed to prevent flattening of the occipital bones?

1. Allow the infant to sleep on his abdomen while an adult is present and observing the infant during sleep.

2. Wrap the occipital portion of the infant’s head with an ace bandage for 20 minutes each day.

3. Alternate the head position from left to right during sleep.

4. Place an infant hat on the head of the infant during sleep for the first three months of life.

Answer: 3 Rationale: 1. The infant should not be allowed to sleep on his abdomen even when observed.

2. It is not necessary to wrap the infant’s occipital portion of the infant’s head.

3. Changing the position of the infant’s head while sleeping, especially during the first three months of life, will help alleviate the flattening of the occipital bone due to supine positioning during sleep.

4. An infant hat will not keep the occipital bones from flattening.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 10-6. Intervene with newborns and their families to integrate activities to promote health and to prevent disease and injury.

13. The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which of these instructions should the nurse give as disease prevention strategies? Select all that apply.

1. Routine metabolic screening 2. Hearing screening 3. Formula safety 4. SIDS risk reduction 5. Toilet training Answer: 1, 2, 3, 4

Rationale: 1. Several disease prevention strategies are used during anticipatory guidance for the parents of newborns. Metabolic screening as part of the newborn screening tests, hearing screening, eye examinations, immunizations, prevention of secondhand smoke exposure, SIDS risk reduction, formula safety, handwashing, and minimizing the exposure to disease are among them.

2. Several disease prevention strategies are used during anticipatory guidance for the parents of newborns. Metabolic screening as part of the newborn screening tests, hearing screening, eye examinations, immunizations, prevention of secondhand smoke exposure, SIDS risk reduction, formula safety, handwashing, and minimizing the exposure to disease are among them.

3. Several disease prevention strategies are used during anticipatory guidance for the parents of newborns. Metabolic screening as part of the newborn screening tests, hearing screening, eye examinations, immunizations, prevention of secondhand smoke exposure, SIDS risk reduction, formula safety, handwashing, and minimizing the exposure to disease are among them.

4. Several disease prevention strategies are used during anticipatory guidance for the parents of newborns. Metabolic screening as part of the newborn screening tests, hearing screening, eye examinations, immunizations, prevention of secondhand smoke exposure, SIDS risk reduction, formula safety, handwashing, and minimizing the exposure to disease are among them.

5. It is too early for a discussion on toilet training.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 10-6. Intervene with newborns and their families to integrate activities to promote health and to prevent disease and injury.

14. A nurse observes a mother talking softly to her newborn in the pediatric clinic waiting room. The mother is also caring for her twin 2-year-olds. The twins are running around the waiting room, and the mother yells at them three times within five minutes. Which nursing diagnosis should the nurse formulate?

1. Impaired Attachment, risk for, parent/infant/child 2. Parent Anxiety related to demands of motherhood 3. Role Conflict: positive infant attachment; negative toddler attachment 4. Potential for injury of newborn related to out-of-control behavior of siblings Answer: 2 Rationale:

1. There is no indication the mother is having difficulty attaching to her infant or older children.

2. This mother, now caring for a newborn and active twins, is displaying anxiety by yelling at the twins.

3. This scenario is more indicative of stress and anxiety than of lack of attachment.

4. There is no indication the newborn is in any danger due to the behavior of the twin siblings.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Diagnosis

Learning Outcome: 10-7. Synthesize data from history and examination of the newborn and family to plan approaches useful with the family during health supervision encounters.

15. A mother asks the nurse about feeding her infant. The nurse’s best response that includes the recommendation made by the American Academy of Pediatrics (AAP) concerning feeding infants is: 1. Breastfeed exclusively for the first year of life.

2. Introduce solid foods beginning at 4 months of age.

3. Begin exclusive breastfeeding with no water, juice, or other foods.

4. Introduce table foods only after tooth eruption.

Answer: 3

Rationale: 1. The AAP does not recommend exclusive breastfeeding for the first year of life. These infants would be at risk for experiencing nutritional deficiencies.

2. A variety of solid foods should not be introduced at 4 months of age, since the infant cannot digest many foods.

3. Breast milk is the preferred method of feeding infants in the first six months of life.

4. Solid infant foods can be introduced at 6 months of age regardless of the status of tooth eruption, since the foods are all pureed.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 10-8. Describe the advantages of breastfeeding, and the nurse’s role in breastfeeding promotion.

16. A pregnant woman is planning to breastfeed. The nursing intervention that will promote breastfeeding in the new mother is: 1. Facilitating breastfeeding within the first 30–60 minutes of life.

2. Giving the woman literature on breastfeeding as soon as she enters the labor room.

3. Telling the mother that the physician strongly advises new mothers to breastfeed their newborns.

4. Encouraging the mother to attend breastfeeding classes before discharge from the hospital.

Answer: 1 Rationale: 1. The literature shows that the mother who has the opportunity to breastfeed her infant within the first 30–60 minutes after birth facilitates breastfeeding later.

2. The mother in labor is not going to be able to focus on learning to breastfeed.

3. The mother will make the decision based on her feelings, not on what the physician says.

4. While this is a good intervention to prepare the mother, the best intervention occurs after the infant is born, while the mother is focused on the newborn.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Intervention

Learning Outcome: 10-8. Describe the advantages of breastfeeding, and the nurse’s role in breastfeeding promotion.

1. A nurse is teaching a group of postpartum women about well-child care. What is the best instruction the nurse should provide about when an infant should be seen for health supervision visits?

1. Every month for the first year of life 2. Every other month for the first year of life 3. At 1 month, 2 months, 4 months, 6 months, 9 months, and 12 months 4. When the mother feels that the infant is showing signs of illness Answer: 3 Rationale: 1. To see the infant on a monthly basis is too frequent for a healthy infant.

2. If the infant is seen every other month, certain common conditions could be missed at 2 months.

3. Schedules do vary among health care providers; however, the infant should be seen at 1 month, 2 months, 4 months, 6 months, 9 months, and 12 months for health supervision, immunizations, and disease prevention strategies.

4. If parents bring the infant to the health care provider only when the infant is ill, the infant would miss all routine health care visits.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Learning Outcome:Implementation 11-1Describe the general observations made of infants and their Nursing Process: families as they come to the pediatric health care home for health supervision visits.

2. A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the measurements two months ago were at the 25th percentile. How should the nurse interpret these data?

1. The infant is not gaining enough weight.

2. The infant has gained a significant amount of weight.

3. The previous measurements were most likely inaccurate.

4. These measurements most likely are inaccurate.

Answer: 2 Rationale: 1. This infant has gained significant weight to move up two percentiles.

2. A comparison of these two sets of measurements shows that the infant has crossed two percentiles, going from the 25th to the 75th percentile, and therefore has gained a significant amount of weight.

3. This is an assumption that the nurse cannot make.

4. If the nurse believes them to be inaccurate, then they should be repeated immediately.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome: 11-1 Describe the general observations made of infants and their families as they come to the pediatric health care home for health supervision visits.

3. The nurse working with a family has observed that the older children have a large number of dental caries, and so plans to provide the mother with information to prevent the development of dental caries in her new infant. Which of these interventions prevent the development of dental caries in infants? Select all that apply.

1. Wiping the infant’s gums with soft moist gauze once or twice daily 2. Avoiding nursing or giving the infant a bottle at bedtime 3. Giving foods high in sugar only at breakfast time 4. Using a toothbrush as soon as the first tooth erupts 5. Using a topical anesthetic daily, beginning as soon as the first tooth begins to erupt Answer: 1, 2 Rationale: 1. The only options given that will assist in the prevention of dental caries are wiping the gums with a soft moist gauze and avoiding putting the infant to bed with a bottle.

2. The only options given that will assist in the prevention of dental caries are wiping the gums with a soft moist gauze and avoiding putting the infant to bed with a bottle.

3. Foods high in sugar should be avoided in the infant period.

4. A toothbrush should not be used during infancy.

5. Topical anesthetic should not be applied daily.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 11-2Identify the major health promotion and maintenance needs during infancy.

4. A nurse is planning to teach a group of teenage mothers health promotion strategies for infant care. Which of these strategies should the nurse include in the teaching plan? Select all that apply.

1. Playing with the infant each day 2. Vocalizing frequently to the infant

3. Providing for basic physical and emotional needs of infant 4. Placing the infant in the crib and going out of the house for about 30 minutes if the mother is feeling frustrated with infant care 5. Disciplining the infant, such as slapping the infant’s hand to teach right from wrong Answer: 1, 2, 3 Rationale: 1. Playing and talking with the infant and meeting the infant’s basic needs are most important for infant growth and development.

2. Playing and talking with the infant and meeting the infant’s basic needs are most important for infant growth and development.

3. Playing and talking with the infant and meeting the infant’s basic needs are most important for infant growth and development.

4. The nurse should never advise the mother to leave the infant alone in the house.

5. It is not appropriate to slap an infant, or any child.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 11-2Identify the major health promotion and maintenance needs during infancy.

5. A nurse who is assigned to the ambulatory pediatric outpatient health care center is asked to assess a family for protective factors. These include: (Select all that apply.)

1. Financial resources of the families.

2. Family stressors.

3. Knowledge of infant care needs.

4. Support from family and friends. 5. Mother’s nutritional state during pregnancy.

Answer: 3, 4, 5 Rationale: 1. Risk factors include the family’s financial resources and family stressors.

2. Risk factors include the family’s financial resources and family stressors.

3. Protective services include knowledge of infant care, support of family and friends, and the mother’s nutritional status during pregnancy.

4. Protective services include knowledge of infant care, support of family and friends, and the mother’s nutritional status during pregnancy.

5. Protective services include knowledge of infant care, support of family and friends, and the mother’s nutritional status during pregnancy.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome: 11-3Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of infants.

6. A nurse is assessing an 11-month-old, and notes that the infant’s height and weight are at the 5th percentile on the growth chart. Family history reveals that the infant’s two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority?

1. Nutritional Intake: excessive secondary to maternal feeding patterns 2. Growth Pattern, Altered secondary to familial short stature 3. Growth Pattern, Altered related to parental anxiety

4. Constitutional Growth Delay, risk for related to decreased appetite Answer: 3 Rationale: 1. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake.

2. There are no data that indicate familial short stature.

3. The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is Growth Patterns, Altered related to parental anxiety.

4. This infant is not at risk for constitutional growth delay.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Diagnosis Learning Outcome: 11-3 Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of infants.

7. A 10-month-old infant is admitted to the hospital with a medical diagnosis of dehydration. A nursing assessment reveals decreased vocalization, general lack of interest in the surroundings, and non-engaging behaviors. Which of these nursing actions takes priority?

1. Allowing the infant to rest quietly and undisturbed in the crib 2. Monitoring the mother’s affect 3. Monitoring the infant’s response to vocalization when the nurse enters the room 4. Holding and cuddling the infant frequently throughout the day Answer: 2 Rationale: 1. The infant should not be left in the crib undisturbed.

2. The scenario reveals inappropriate infant behaviors. This is a priority question, so all answers

might be correct, and you need to select the answer that shows which action should be completed first. The nurse needs to monitor the mother–infant interaction.

3. Monitoring the mother’s affect is the priority.

4. The infant should be held and cuddled throughout the day; however, the best answer related to problem identification is observing the mother’s affective behavior.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 11-3Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of infants.

8. A nurse asks the mother of a 4-month-old to undress the infant. The nurse observes the mother taking off several layers of clothing, knowing that the outdoor temperature is 70°F. Which of these statements should the nurse make to the mother?

1. “My, you are dressing your infant warmly today.”

2. “Did you think it was it cold when you left your home this morning?”

3. “I see that you have many layers of clothing on your baby. This could cause your baby’s temperature to rise.”

4. “When you leave the office, only put one layer of clothing on your baby.”

Answer: 3 Rationale: 1. Making a statement on how warmly the child is dressed will not necessarily accomplish this goal.

2. This comment might cause the mother to become defensive, and so is not helpful to the mother.

3. In this scenario, the mother has overdressed the infant. The nurse needs to inform the mother of this problem gently, and to provide information to the mother on why it is a problem.

4. Telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, and so is not helpful to the mother.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 11-4 Apply therapeutic communication skills with the infant and family during health supervision visits in infancy.

9. The parents of an 8-month-old infant are very distressed that the infant cries for at least one hour when they go out on Friday nights. Which of these statements should the nurse make to the parents?

1. “Your infant is too young to be experiencing stranger anxiety; however, you might need to stop going out on Friday nights for a while.”

2. “Do you think your infant is in pain?”

3. “Oh, don’t worry. All infants and toddlers display these behaviors until at least 2½ years old.”

4. “Your infant is attached to you. This is an expected infant response.”

Answer: 4 Rationale: 1. 8-month-old infants do experience stranger anxiety.

2. There is no indication that the infant would be in pain on a weekly basis.

3. This is a non-therapeutic response. Infants usually stop experiencing stranger anxiety before 2½ years of age.

4. The best response is an explanation to the parents on attachment behaviors, and assurance that this is a normal infant response.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 11-4Apply therapeutic communication skills with the infant and family during health supervision visits in infancy.

10. A new mother has been taught that her infant needs to be seen in the pediatrician’s office for the initial health care visit. The mother asks the nurse what the purpose of this visit will be. The nurse explains that during this initial visit, the nurse will: (Select all that apply.)

1. Discuss policies related to provision of care.

2. Evaluate the parents’ understanding of the services offered.

3. Determine if the parents and health care provider’s personalities are compatible.

4. Determine whether the parents are child abusers.

5. Determine whether the parents will make their infant obese.

Answer: 1, 2, 3 Rationale: 1. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and provider will get along well.

2. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and provider will get along well.

3. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and provider will get along well.

4. Only under very unusual circumstances would the health care providers be able to determine whether the parents are potential child abusers 5. Only under very unusual circumstances would the health care providers be able to determine whether the parents will tend to overfeed the infant and place the infant at risk for obesity.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 11-5 Intervene with infants and their families to integrate activities to promote health and to prevent disease and injury.

11. The nurse is working in a well-child clinic. The nurse will include which of these health promotion strategies in the first well-care infant visit?

1. Encouraging activities that will help the infant meet developmental milestones 2. Questioning the parents about current birth control methods to reduce the possibility of another pregnancy 3. Instructing the mother to avoid the introduction of new foods until the infant is 8 months old 4. Instructing the parent to place the infant in a prone position to sleep Answer: 1 Rationale: 1. One of the main goals of the first health care visit is to inform the parents of ways they can help the infant meet developmental milestones.

2. Questioning about birth control is not appropriate.

3. Cereal and fruits may be introduced at 6 months of age.

4. Recommendation for sleep for the infant is in the supine position.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 11-5Intervene with infants and their families to integrate activities to promote health and to prevent disease and injury.

12. The nurse is working with first-time parents. Which of these activities will the nurse suggest to encourage the development of good muscle tone?

1. Placing the infant in an infant seat rather than lying down in a crib 2. Putting the infant to bed each night at 8 p.m., even if the infant protests with crying 3. Swaddling the infant 4. Surrounding the infant with toys and other stimulating items to encourage motor movement Answer: 4 Rationale: 1. An infant seat restricts movement, which would not encourage muscle tone development.

2. The bedtime has nothing to do with development of infant muscle tone.

3. Swaddling the infant, while calming for a young infant, restricts movement.

4. Encouraging movement best assists the infant to obtain good muscle tone.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 11-5 Intervene with infants and their families to integrate activities to promote health and to prevent disease and injury.

13. An infant is growing slowly, and the weight on the growth chart has remained at–2 standard deviations (–2 SD). Which of these interventions takes priority?

1. Ask for a recall of the infant’s intake in the previous day.

2. Question the mother about developmental milestones. 3. Report the case to Child Protective Services. 4. Firmly instruct the family about appropriate dietary intake for the infant. Answer: 1 Rationale: 1. The nurse needs to obtain a nutritional history on this infant. Obtaining a 24-hour dietary recall on the infant is most appropriate.

2. Questioning developmental milestones would not lead to any conclusions about the problem presented.

3. There is no indication for reporting this parent to Child Protective Services.

4. Providing instruction on dietary intake without a nutritional history would not be appropriate.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 11-6Synthesize data from history and examination of the infant and family with knowledge of infant development to plan approaches useful for the family during health supervision encounters.

14. An infant is born at 24 weeks’ gestational age. Which of these interventions should the nurse plan when the infant is discharged home?

1. Referring the infant for developmental screening 2. Instructing the parents that sterilization of infant bottles and nipples is not necessary 3. Giving the parents information on HIV screening that is necessary for infants born at this gestational age

4. No particular instructions are necessary, since discharge teaching is completed immediately after the birth of the infant.

Answer: 1 Rationale: 1. Premature infants need to be referred for developmental assessment soon after discharge from the hospital.

2. Sterilization of bottles and nipples is necessary for infants until 3 months of age.

3. HIV testing would have been completed during the immediate newborn period.

4. Discharge instructions are given multiple times during the infant’s stay in the hospital, and would need to be repeated again and written prior to discharge.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 11-6 Synthesize data from history and examination of the infant and family with knowledge of infant development to plan approaches useful for the family during health supervision encounters.

15. A foster mother is caring for an infant who experienced an intrauterine drug exposure to cocaine. The infant often is irritated, and cries for several hours each day. Which of these interventions will assist the infant in developing self-regulatory behaviors?

1. Encouraging the infant to suck as a comfort measure by placing the infant’s fingers in the mouth while crying 2. Allowing the infant to cry but observing the infant to prevent injury 3. Swaddling the infant 4 Placing the infant about 15 inches from the TV and turning on an infant show suchSesame as Street Answer: 3

Rationale: 1. Sucking can be a comfort measure for infants, but the infant should not be given her own fingers.

2. The infant cannot be left to cry for several hours, but should be taught to trust caregivers through swaddling.

3. Infants exposed to intrauterine drugs and/or alcohol are irritable after birth. These infants respond best to swaddling in the first few months of life.

4. Infants should not be watching television from any distance.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 11-6 Synthesize data from history and examination of the infant and family with knowledge of infant development to plan approaches useful for the family during health supervision encounters.

Chapter 12

1. The nurse is explaining the primary purpose of performing health maintenance activities at each pediatric visit. The best explanation touches on: 1. Prevention of disease and injury.

2. Teaching growth and development to the parents.

3. Reviewing developmental milestones with the parents.

4. Planning appropriate disciplinary measures for control of behavior.

Answer: 1 Rationale: 1. The primary purpose of health maintenance activities is prevention of disease and injury for children of all ages.

2. While it is important for parents to understand the normal growth and development, developmental milestones, and age-appropriate discipline measures for children of all ages, these are not the primary purposes of performing health maintenance activities at each pediatric visit.

3. While it is important for parents to understand the normal growth and development, developmental milestones, and age-appropriate discipline measures for children of all ages, these are not the primary purposes of performing health maintenance activities at each pediatric visit.

4. While it is important for parents to understand the normal growth and development, Learning Outcome: 12-1 Describe the general observations made of toddlers/preschoolers developmental milestones, and age-appropriate discipline measures for children of all ages, and thesetheir families as they come to the pediatric health care home for health supervision visits. are not the primary purposes of performing health maintenance activities at each pediatric visit.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation

2. Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old? Select all that apply.

1. Always feeds self.

2. Scribbles and draws on paper.

3. Kicks a ball.

4. Throws ball overhand.

5. Goes up and down stairs.

Answer: 2, 3, 5 Rationale: 1. Children between the ages of 3 and 4 years old feed themselves.

2. Children between the ages of 2 and 3 years old can scribble and draw on paper.

3. Children between the ages of 2 and 3 years old can kick a ball.

4. Children between the ages of 4 and 5 years can throw a ball overhead.

5. Children between the ages of 2 and 3 years old can go up and down stairs.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 12-1 Describe the general observations made of toddlers/preschoolers and their families as they come to the pediatric health care home for health supervision visits.

3. The parent and/or family situation that most likely offers a sense of security for the preschooler in the home environment would be:

1. Parents and grandparents who live in the same household and share the care of the preschooler.

2. Families who yell with each other but then have a “group hug” to end the disagreement.

3. Parents who tell the toddler “no” firmly every time the toddler does something inappropriate.

4. Parents who handle stress well.

Answer: 4 Rationale: 1. While many families have extended family members (grandparents) living in the same household, this is not necessary to achieve a secure home environment.

2. Families who yell and then do a “group hug” are giving confusing messages to the children in the home.

3. Constantly telling a toddler “no” reinforces negativity, and is not a recommended method for working with toddlers.

4. Parents who handle stress well set the tone of the household and offer the child a sense of security in the home environment.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 12-1 Describe the general observations made of toddlers/preschoolers and their families as they come to the pediatric health care home for health supervision visits.

4. A parent says to a nurse, “My 4-year-old has five cavities.” The nurse informs the parent that early-childhood caries is related to which of the following?

1. Strong familial history of dental caries 2. Inadequate preventive care, including brushing the teeth and eating habits 3. Increased intake of iron supplements 4. Fluoride intake in water and in toothpaste Answer: 2 Rationale: 1. Dental caries is not hereditary.

2. Early-childhood caries are related to inadequate preventive care, which can include diet, brushing, and feeding habits.

3. Iron intake is not related to dental caries.

4. While fluoride intake is needed for strong, healthy teeth, poor dental hygiene is responsible for dental caries.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcomes: 12-2Identify the major health concerns of toddlers and preschoolers.

5. A nurse should provide anticipatory guidance to parents of toddlers and preschoolers concerning injury prevention. Which of these injuries should the nurse identify as occurring in toddlers and preschoolers? Select all that apply.

1. Drowning 2. Falls

3. Sports injuries 4. Poisoning Answer: 1, 2, 4 Rationale: 1. Injuries that occur frequently in toddlers and preschoolers include drowning, falls, and poisonings.

2. Injuries that occur frequently in toddlers and preschoolers include drowning, falls, and poisonings.

3. Sports injuries usually occur in older children.

4. Injuries that occur frequently in toddlers and preschoolers include drowning, falls, and poisonings.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcomes: 12-2Identify the major health concerns of toddlers and preschoolers.

6. A nurse who is the manager of an ambulatory pediatric health care center is planning protocols for the routine health care visits of the children. Children within the catchment area of this care center have a high incidence of obesity. The nurse should ask all nurses to calculate the body mass index (BMI) for all pediatric clients at which age?

1. 12 months 2. 24 months 3. 36 months 4. 4 years

Answer: 2 Rationale: 1. This is too early to calculate BMI. 2. The body mass index is first calculated at 2 years of age, and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that can reduce the incidence of obesity.

3. This is too early to calculate BMI. 4. This is too early to calculate BMI. Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome: 12-3 Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of toddlers and preschoolers.

7. A nurse is preparing to perform a physical assessment on a toddler. Which of these actions should the nurse take?

1. Perform the assessment from head to toe.

2. Leave intrusive procedures such as ear and eye examinations until the end.

3. Explain each part of the examination to the child before performing it.

4. Ask the mother to tell the child not to be afraid.

Answer: 2 Rationale:

1. The nurse should complete the assessment in whichever order does not upset the child, leaving the head and genital areas for last.

2. Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be

done last to decrease the anxiety of the child during the initial phases of the examination, which include the heart and lungs.

3. Explaining each part before performing it will only make the child more fearful, as it will make the entire procedure last longer.

4. This will do little to alleviate the child’s fears.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Intervention Learning Outcome: 12-3 Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of toddlers and preschoolers.

8. The nurse discusses which activities for a preschooler that are related to kinesthesia? Select all that apply.

1. Skipping 2. Walking on a balance beam 3. Playing a memory game 4. Reading 5. Giving up a pacifier Answer: 1, 2 Rationale: 1. Kinesthesia is the sense of one’s body position and movement, and develops during the preschool years. Such activities include skipping, walking on a balance beam, and throwing and catching a ball.

2. Kinesthesia is the sense of one’s body position and movement, and develops during the preschool years. Such activities include skipping, walking on a balance beam, and throwing and catching a ball.

3. Playing a memory game and reading are cognitive activities. 4. Playing a memory game and reading are cognitive activities. 5. A pacifier is used to soothe and calm infants.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 12-3 Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of toddlers and preschoolers.

9. A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which of these actions by the nurse takes priority?

1. Instruct the father to hold the toddler down tightly to complete the examination.

2. Allow the toddler to sit on the parent’s lap and begin the assessment.

3. Allow the toddler to stand on the floor until the crying stops.

4. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler’s behavior.

Answer: 2 Rationale:

1. The father should not be asked to restrain the child for the entire examination.

2. Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way.

3. Allowing the toddler to stand on the floor is inappropriate.

4. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 12-4: Apply therapeutic communication skills with the toddler/preschooler and family during health supervision visits in toddlerhood/preschool.

10. Parents of a preschool-age child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents?

1. “Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child.”

2. “Let’s talk about other forms of discipline that have a more positive effect on the child.”

3. “Can you try only spanking the child every other day for one week and see how that affects the child’s behavior?”

4. “I think you are not parenting your child properly, so let’s talk about ways to improve your parenting skills.”

Answer: 2 Rationale: 1. To suggest spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

2. The behavior reported by the parent was excessive. The only response that is appropriate is to seek a more positive way of influencing behavior in this age child.

3. Making the suggestion for parents to spank even every other day for one week is inappropriate.

4. This comment is inappropriate, and will cause the parents to become defensive of their

actions.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 12-4: Apply therapeutic communication skills with the toddler/preschooler and family during health supervision visits in toddlerhood/preschool.

11. A parent questions how her toddler will interact with other toddlers. The nurse’s best description of the differences in play between the toddler and the preschooler is: 1. Toddlers play “side by side,” while preschoolers play cooperatively.

2. Toddlers play house and imitate adult roles, while preschoolers become the “mom or dad” while playing house.

3. Toddlers play cooperatively, while preschoolers play interactive games.

4. There are no differences between toddlers and preschoolers, since both play cooperatively.

Answer: 1 Rationale: 1. Toddlers, although they will play “side by side” with another child, do not interact with the child during play.

2. Toddlers do not play house or imitate the adult roles.

3. Preschoolers play cooperatively with other children.

4. Only preschoolers play cooperatively with other children.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 12-4:Apply therapeutic communication skills with the toddler/preschooler and family during health supervision visits in toddlerhood/preschool.

12. Which of these aspects of developmental health supervision should be included in each health care visit of young children? Select all that apply.

1. Assessment 2. Discipline 3. Education 4. Intervention 5. Toilet training Answer: 1, 3, 4 Rationale: 1. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each health care visit.

2. Discipline, while important to the care of children, is age-specific, and not part of the main developmental plans.

3. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each health care visit.

4. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each health care visit.

5. Toilet training, while important to the care of children, is age-specific, and not part of the main developmental plans.

Cognitive Level: Assessment Client Need: Health Promotion and Maintenance Nursing Process: Planning

Learning Outcome 12-5:Intervene with toddlers/preschoolers and their families to integrate activities to promote health and to prevent disease and injury.

13. A nurse instructs a parent of a preschooler to use the “five-a-day” rule for feeding the preschooler, a rule that relates to:

1. Chicken and at least two servings of red meat per week.

2. Milk and milk products.

3. Fruits and vegetables.

4. Breads and cereals.

Answer: 3 Rationale:

1. A preschooler does not need at least two servings of red meat per week.

2. A preschooler does not need five servings of milk and milk products a day.

3. Five servings of fruits and vegetables each day are needed for toddlers and preschoolers to help boost the immune system, provide regular bowel patterns, and promote healthy hair and nails.

4. A preschooler does not require five servings of bread or cereal a day.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 12-5:Intervene with toddlers/preschoolers and their families to integrate activities to promote health and to prevent disease and injury.

14. At a routine health care visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data?

1. The toddler is proportionate for age.

2. The toddler needs to eat more at each feeding.

3. The height and weight are disproportionate, and the toddler needs further evaluation.

4. The family most likely is short.

Answer: 3 Rationale: 1. The height and weight for the child described in this question are a concern, and the child might need further endocrine testing.

2. Eating more will increase the child’s weight but might do nothing to increase height. Further evaluation is needed.

3. Usually, height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child’s height usually also is greater than the 50th percentile.

4. The family might be short, but a difference this great between height and weight needs to be referred for further evaluation and testing.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 12-6 Synthesize data from the history and examination of the toddler/preschooler and family with knowledge of toddler/preschooler development to plan approaches useful with the family during health supervision encounters.

15. Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile?

1. Discussing the growth of the toddler as compared with the growth chart 2. Suggesting ways to have the toddler eat higher-calorie foods 3. Instructing the mother to feed the toddler alone without any distractions, such as TV or music 4. Teaching the mother to avoid disciplining the toddler within 30 minutes of eating Answer: 1 Rationale: 1. Showing the parents the growth pattern of the child as compared with the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years.

2. Toddlers who are at the 50th percentile do not need additional high-calorie foods.

3. Toddlers eat to their personal needs, and there is no medical reason to restrict watching TV or other environmental stimuli during meals.

4. There is no reason to relate timing of discipline and eating.

Learning Outcome: 12-6 Synthesize data from the history and examination of the Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing toddler/preschooler and family with knowledge of toddler/preschooler development to Process: Implementation plan approaches useful with the family during health supervision encounters.

1. A nurse observes the parent–child interaction during the 6-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial?

1. “Perhaps you should leave the room so that I can speak with your child privately.”

2. “I am going to refer you for counseling, since your interactions with your child seem so negative.”

3. “Let’s talk privately. Let’s discuss the way you speak with your child, and possible ways to be more positive.”

4. Addressing the child, the nurse says, “Are you unhappy when Mommy talks to you like this?”

Correct Answer: 3 Rationale: 1. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child.

2. It is not appropriate to refer them to counseling without a discussion with the parent.

3. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation.

4. The nurse should not ask the child if she is “unhappy” with the parent.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 13-1: Describe the general observations made of school-age children and their families as they come to the pediatric health care home for health supervision visits.

2. The school health nurse recognizes that children who display certain characteristics are at risk for poor school performance. Which would be most likely to cause poor school performance?

1. Decreased ability to perform visual tracking 2. Increased auditory stimulation 3. Increase muscle tone 4. Multiple dental caries Correct Answer: 1 Rationale: 1. Children with a deficit in vision, hearing, and muscle tone are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity.

2. Decreased, not increased, hearing can lead to school performance issues.

3. Decreased muscle tone is a risk factor for having problems at school.

4. School performance would least likely be affected by dental caries.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 13-1: Describe the general observations made of school-age children and their families as they come to the pediatric health care home for health supervision visits.

3. Poor school performance can be exhibited by school-age children exhibiting which characteristic?

1. Decreased auditory stimulation 2. Increase muscle tone 3. Multiple dental caries

4. Chronic tonsillitis Correct Answer: 1 Rationale: 1. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity.

2. A decrease in muscle tone would most likely cause problems at school.

3. School performance is not likely affected by dental caries.

4. School performance is not likely affected by chronic tonsillitis.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 13-1: Describe the general observations made of school-age children and their families as they come to the pediatric health care home for health supervision visits.

4. Which of these characteristics displayed by school-age children would be least likely to be a risk factor for poor school performance?

1. Increased ability to perform visual tracking 2. Increased auditory stimulation 3. Decreased muscle tone 4. Multiple dental caries Correct Answer: 3

Rationale: 1. A decrease in ability to track visually would be a risk factor for poor school performance.

2. A decrease in auditory stimulation would be a risk factor for poor school performance.

3. Children with problems with muscle tone are at risk for poor school performance, since many school activities involve kinetic activity.

4. School performance be least likely to be affected by dental caries.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 13-1: Describe the general observations made of school-age children and their families as they come to the pediatric health care home for health supervision visits.

5. Which of these aspects of developmental health supervision should be included in each health care visit of young children?

1. Discipline 2. Education 3. Diagnosis 4. Toilet training Correct Answer : 2 Rationale: 1. Discipline, while important to the care of children, is age-specific, and not part of the main developmental plan.

2. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each health care visit.

3. It should not be necessary for a diagnosis at a developmental health supervision visit.

4. Toilet training is age-specific, and does not need to be part of developmental health visits.

Cognitive Level: Assessment

Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 13-1: Describe the general observations made of school-age children and their families as they come to the pediatric health care home for health supervision visits.

6. A nurse obtains a nutritional health history from a 10-year-old child. Which of these food selections, if consumed on a regular basis, should lead the nurse to become concerned about the need for improving oral hygiene?

1. Peanuts and crackers 2. Sorbet and yogurt 3. Gummy bears and licorice 4. Fluoridated water.

Correct Answer: 3 Rationale: 1. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth, and are not considered foods that increase dental caries.

2. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth, and are not considered foods that increase dental caries.

3. Items such as gummy bears and licorice stick to the teeth and lead to dental caries.

4. Fluoridated water has been shown to decrease the incidence of dental caries.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 13-2: Identify the major health concerns of school-age children.

7. A 9-year-old child who has been followed in the same pediatric health care home since birth is at the health care center for a well-child visit. A nurse who measures the height and weight of the child documents 35th percentile for height and 90th percentile for weight. How should the nurse interpret these data?

1. The child is beginning a growth spurt.

2. The child is obese, and needs dietary counseling.

3. The parents are most likely below the 50th percentile for height and weight.

4. As soon as the child begins the adolescent growth spurt, the height and weight measurements will normalize.

Correct Answer: 2 Rationale: 1. This is not a growth spurt, since height is what is referred to by the term growth spurt.

2. These data show that the child is disproportionate in height and weight. This child’s weight is very high in comparison with height. The child would appear obese. Dietary history and counseling are the first steps. This child also might need an endocrine evaluation.

3. No assumptions about the parents can be made from the data presented.

4. The statement about the adolescent growth spurt is incorrect for this age child.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 13-2: Identify the major health concerns of school-age child.

8. The nurse is visiting with a school-age child in the clinic. The child states to the nurse, “Friends are giving me cigarettes to smoke.” What is the best response by the nurse?

1. “There are many risks you take when you choose to smoke.”

2. “Smoking occasionally will not hurt you” 3. “Tell them ‘no,’ don’t do it again, and don’t tell anyone” 4. “I will show you a model of lungs, and then I want you to breathe through a straw.”

Correct Answer: 4

Rationale: 1. A school-age child will not remember or really care about hearing the risks of smoking.

2. Smoking occasionally will hurt the child’s health, so this response is inappropriate.

3. The school-age child wants to be like his peers, and won’t just tell friends no without a justification.

4. When teaching about smoking, providing a model of lungs and having the child breathe through a straw demonstrate the effects of airway narrowing. This makes the effects much more realistic.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 13-2: Identify the major health concerns of school-age child.

9. A 6-year-old child is being seen by the nurse for well-child checkup. The parent tells the nurse that they live on a farm and their water supply is from a well. Which should be the nurse’s main concern?

1. Use of fluoride 2. How many teeth have been lost 3. Use of teeth whitener 4. Use of mouthwash Correct Answer: 1 Rationale: 1. Many changes occur in the mouth during school-age years, necessitating periodic examination. Inquire about use of fluoride if the water supply is not fluoridated. Well water does not contain fluoride.

2. Asking about the number of teeth lost is not as important as finding out whether fluoride is in use.

3. Teeth whitener is not mentioned in the scenario, and while the nurse would be concerned if a 6-year-old was using it, fluoride use is more important.

4. Mouthwash use in a 6-year-old is not as important as asking about fluoride use.

Cognitive Level: Assessment

Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 13-2: Identify the major health concerns of school-age child.

10. A 6-year-old is visiting with the nurse. The mother states, “I think my child is eating too much candy; she lost her front tooth.” Which response by the nurse is most appropriate?

1. “Has she lost any other teeth?”

2. “How much candy does your child eat a day?”

3. “She is young; it will grow back.”

4. “What type of candy does she eat?”

Correct Answer: 1

Rationale: 1. Many changes occur in the mouth during the school-age years, necessitating periodic examination. At about 6 years of age, most children lose a tooth, and the front teeth usually are first.

2. While the nurse needs to know about total candy consumption, the priority is finding out how many other teeth the child has lost.

3. The child probably lost the tooth because it was time for the baby tooth to fall out to make room for the permanent tooth.

4. What type of candy the child eats is not the priority.

Cognitive Level: Assessment Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 13-2: Identify the major health concerns of school-age child.

11. At a routine health care visit, a nurse measures a school-age child and plots the height and weight on the growth charts. The nurse documents that the school-age child is above the 95th percentile for weight and is at the fifth percentile for height, where it has been for a few years.

How should the nurse interpret these data?

1. The school-age child is proportionate for the age.

2. The school-age child needs to eat more at each feeding.

3. The height and weight are disproportionate, and the child needs further evaluation.

4. The family is most likely short in stature Correct Answer: 3 Rationale: 1. The child’s height and weight are disproportionate for this child, and she needs to be evaluated.

2. Because the weight is at the 95th percentile, eating more food will not solve the problem. The problem lies in the height for this child.

3. Usually height and weight are at approximately the same percentile. Usually when the weight of a child is found to be at the 95th percentile, the child’s height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child might need further endocrine testing.

4. There is not enough information to determine the stature of the family.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome 13-3: Apply assessment skills to gather data regarding nutrition, physical activity, oral health, mental health status, and growth and development of school-age children.

12. The nurse is caring for a young child in the clinic. The mother tells the nurse the child sleepwalks every night. Which statement by the nurse is appropriate?

1. “Are you concerned the child is not getting enough sleep?”

2. “What time does your child goes to bed at night?”

3. “Is the child experiencing any stress at home?”

4. “What do you know about children who sleepwalk?”

Correct Answer: 3

Rationale: 1. The nurse is more concerned about the reason the child is sleepwalking, not about the amount of sleep the child is getting.

2. The nurse is concerned about the reason the child is sleepwalking, not about the child’s nighttime routine.

3. Sleepwalking and sleeptalking sometime occur in school-age children, but usually decrease as the child nears adolescence. Children who have stress at home, such as parental fighting, ill family members, or inadequate food and shelter, often have increased incidence of sleepwalking.

4. It is not necessary to ask this question of this mother at this time. It is more important to determine why the child is sleepwalking.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Intervention

Learning Outcome 13-3: Apply assessment skills to gather data regarding nutrition, physical activity, oral health, mental health status, and growth and development of school-age children.

13. While teaching the parent of school-age children about self-esteem, the nurse instructs the parents to: 1. Build on the child’s strengths and talents.

2. Not point out the child’s ability.

3. Limit the amount of compliments given to the child.

4. Establish the goals they want the child to achieve at certain time.

Correct Answer: 1 Rationale: 1. Parents play an important part in fostering the child’s self-esteem. Building on the child’s strengths and talents and always pointing out the child’s abilities increase the child’s self-esteem.

2. In trying to build self-esteem in a child, it is important to talk about the child’s abilities.

3. Complimenting a child’s strengths is important to increase self-esteem.

4. Setting goals for the child to reach at a certain time could lead to disappointment if they are not reached on time. This will result in a drop in self-esteem.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 13-3: Apply assessment skills to gather data regarding nutrition, physical activity, oral health, mental health status, and growth and development of school-age children.

14. While teaching the parents of a school-age child about coping with divorce, the nurse instructs the parents to: 1. Share marital concerns with the child.

2. Spend less time with the child so he doesn’t feel the tension between the parents.

3. Be sure the child understands the divorce is not the child’s fault.

4. Allow the child to stay with only one parent until the divorce becomes final.

Correct Answer: 3 Rationale: 1. It is not appropriate for the parents to discuss marital concerns with the child.

2. The parents should spend more time with the child, not less, when experiencing a divorce.

3. Divorce is a common, stressful event for school-age children. While parents are engaged in their own stresses, they might benefit from help to plan for ways to lessen the strain on the children. They can make sure the child understands that the divorce is not the child’s fault and is only related to the parents’ relationship with each other.

4. Staying with only one parent will alienate the child from the opposite parent, and is not an appropriate instruction.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 13-3: Apply assessment skills to gather data regarding nutrition, physical activity, oral health, mental health status, and growth and development of school-age children.

15. During a routine visit, a parent of a school-age child states to the nurse, “I don’t think my child wants me to help with anything anymore.” The best response from the nurse should be: 1. “Continue to do what you have been doing for your child.”

2. “Your child’s ability to solve problems and assume more responsibility for herself is important.”

3. “Just let your child know you are the parent, and that what you are doing is the right thing.”

4. “Let your child know that she should inform you when she needs to have something done.”

Correct Answer: 2 Rationale: 1. If the parent continues to do tasks for the child, the parent–child relationship will suffer.

2. School-age children continue to develop abilities to self-regulate activities and response to situations. At this age, the abilities to solve problems and assume more responsibility for self are important. Encourage the parents to praise the child for assuming responsibilities.

3. It is not appropriate for the parent to insist on doing things for the child, as it will decrease the amount of responsibility the child takes on.

4. The child should not have to inform the parent when she needs to have something done if the child is fully capable to safely do it for herself.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 13-4: Apply therapeutic communication skills with the school-age child and family during health supervision visits.

16. The parents of a school-age child report that they allow their child to eat anything because the child is a “picky” eater. Which is the best response the nurse should make to the parent?

1. “Continue to allow this, because he eventually will begin to eat properly.”

2. “Let’s talk about what types of food are consumed when your child chooses.”

3. “Can you try allowing this to continue but only every other day?”

4. “I think you must not be good role models, so let’s talk about your eating habits.”

Correct Answer: 2

Rationale:

1. The child will never eat properly if the parents do not teach this behavior.

2. Seeking to find a more positive way of influencing the eating behavior in this age group is most appropriate.

3. Eating only the food the child wants, even every other day, does not teach appropriate and healthy food habits.

4. Stating that the parents are not good role models will only make the parents defensive, and therefore is inappropriate.

Cognitive Level: Synthesis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 13-4: Apply therapeutic communication skills with the school-age child and family during health supervision visits.

17. A nurse observes the parent–child interaction during the 9-year-old well-child checkup and notes the child is dressed in a seductive adult manner. Which response by the nurse would be most beneficial?

1. Telling the parent, “I am going to refer you to parenting classes, since your child is dressed inappropriately.”

2. Asking the child, “Are you happy with the way you are dressed?”

3. Asking the mother to leave the room so she can talk with the child alone 4. Telling the parent, “Let’s talk privately. Let’s discuss the way your child is dressed, and possible ways to dress more appropriately.

Correct Answer: 4 Rationale: 1. The nurse should discuss concerns with the parent before any referrals are made.

2. It is not appropriate for the nurse to discuss this concern with the child before discussing it privately with the parent first.

3. It would be inappropriate for the nurse to ask the parent to leave the room to discuss the concern with the child before discussing it privately with the parent first.

4. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Intervention Learning Outcome 13-4: Apply therapeutic communication skills with the school-age child and family during health supervision visits.

18. The school health nurse is evaluating the home environment of several children as it relates to child safety. Which of these activities places a child at greatest risk for bodily harm?

1. The parents are in a methadone program.

2. The parents consume alcohol on a daily basis.

3. The child is permitted to participate in target practice with a revolver, unsupervised.

4. The child is a latchkey child.

Correct Answer: 3 Rationale: 1. The inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms is riskier.

2. The inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms is riskier.

3. Of all the activities mentioned, playing with guns is the greatest risk for injury.

4. A latchkey child needs special attention, but in the current situation, unsupervised gun use is the greatest risk.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 13-5: Intervene with school-age children and their families to integrate activities to promote health and to prevent disease and injury.

19. The school nurse is teaching a class about safety. The nurse will teach the children that they should wear protective athletic gear when participating in selected activities. Which of these activities requires protective athletic gear?

1. Skateboarding 2. Volleyball 3. Swimming 4. Acrobatic tricks Correct Answer: 1 Rationale: 1. Any sport that includes body contact requires a child to wear protective equipment. This includes skateboarding.

2. Swimming, volleyball, and acrobatic tricks do not have any requirements for protective equipment.

3. Swimming, volleyball, and acrobatic tricks do not have any requirements for protective equipment.

4. Swimming, volleyball, and acrobatic tricks do not have any requirements for protective equipment.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation

Learning Outcome 13-5: Intervene with school-age children and their families to integrate activities to promote health and to prevent disease and injury.

20. A class on safety is being taught to parents of children who participate in sports. The parents understand that children think they are immune to accidents and do not need to take precautions when playing sport. Which of the following sports requires protective equipment?

1. Lacrosse 2. Volleyball 3. Swimming 4. Tumbling Correct Answer: 1 Rationale: 1. Any sport that includes body contact requires a child to wear protective equipment. This includes lacrosse.

2. Swimming, tumbling, and volleyball do not have any requirements for protective equipment.

3. Swimming, tumbling, and volleyball do not have any requirements for protective equipment.

4. Swimming, tumbling, and volleyball do not have any requirements for protective equipment.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 13-5: Intervene with school-age children and their families to integrate activities to promote health and to prevent disease and injury.

21. The nurse is performing growth assessments in school-age children. A child states, “I sometimes wake up someplace other than in my bed, and I’m always tired.” What is a possible nursing diagnosis the nurse should include?

1. Sleep Deprivation related to sleepwalking 2. Comfort related to cold temperature 3. Fear related to sleeping in the dark 4. Loneliness related to sleeping alone Correct Answer: 1

Rationale: 1. The child waking up somewhere other than his bed is describing sleepwalking. Thus, the best possible diagnosis is Sleep Deprivation related to sleepwalking.

2. There is no indication that the child is cold.

3. The child does not talk about the inability to sleep because of the dark.

4. There is no indication that the child is fearful in the stem of this question.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Diagnosis Learning Outcome 13-6: Synthesize data from history and examination of school-age child and family with knowledge of school-age development to plan approaches useful with the family during health supervision encounters.

22. The nurse asks the parent during a clinic visit about the nutritional intake of her 8-year-old child. The mother tells the nurse she leaves early for work and her teen sibling takes care of the meals. What response by the nurse regarding nutrition is appropriate?

1. Provide a meal plan for the mother to take to her daughter.

2. Provide information about healthy meals and snacks that are easy for school-age children and teens to prepare

3. Provide sample recipes for the mother.

4. Provide coupons for the mother when going to the grocery store.

Correct Answer: 2 Rationale: 1. Providing a meal plan is not going to help ensure that the child has healthy meals.

2. Provide information about healthy snacks to keep at home, ways to improve calcium intake, and the importance of getting at least five fruit/vegetable serving daily.

3. Sample recipes will not help the mother ensure that her child has healthy meals.

4. Coupons will not help the mother ensure that healthy foods are available for her child.

Cognitive Level: Evaluation Client Need: Health and Promotion Maintenance Nursing Process: Intervention Learning Outcome 13-6: Synthesize data from history and examination of school-age child and family with knowledge of school-age development to plan approaches useful with the family during health supervision encounters.

1. An adolescent is being seen in the clinic to discuss health promotion behaviors. What should the nurse include in the evaluation of the plan?

1. Effectiveness of the plan, and methods to expand and sustain successful approaches

2. The adolescent’s attitude on how the adolescent perceives health

3. Instruction on what is considered healthy behavior

4. Advising the adolescent that promoting health behaviors will maintain a healthy lifestyle Correct Answer: 1 Rationale: 1. When establishing youth programs, whether with individual adolescents or with groups, the nurse includes evaluation of the effectiveness of the plan and methods to expand and sustain successful approaches.

2. Including the adolescent’s attitude toward health has little to do with evaluating the success of the plan.

3. Instruction on healthy behaviors would be included in the implementation phase of the plan.

4. Advising why promoting healthy behaviors is important is part of the implementation phase of the plan.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 14-1: Describe the general observations made of adolescents and their families as they come to the pediatric health care home for health supervision visits.

2. The nurse is preparing to see an adolescent patient to assess relationships with others. What should the nurse do when conducting this assessment?

1. Tell the parents they are not allowed to come into the examination room.

2. Provide time alone with both the adolescent and the parents.

3. Let the parents know the nurse will share the information with them after the exam.

4. Do not ask the parents their opinions of the adolescent’s friends.

Correct Answer: 2 Rationale: 1. The nurse cannot keep the parents out of the examination room, especially if the adolescent wants the parents there.

2. Provide time alone with both the adolescent and the parents so that everyone has time to talk freely and ask questions.

3. The nurse cannot to share the information about the exam, as this is a breach of patient confidentiality.

4. The nurse should include the parents’ opinions of their child’s friends.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 14-1: Describe the general observations made of adolescents and their families as they come to the pediatric health care home for health supervision visits.

3. An adolescent is visiting the clinic for the first time. What should the nurse keep in mind when attending to this patient?

1. Adolescents are comfortable with their surroundings.

2. Adolescents usually are quiet, and will offer no opinions.

3. The nurse should explain procedures and introduce personnel to adolescents.

4. The nurse should attend to adolescents quickly and discharge them.

Correct Answer: 3 Rationale: 1. When adolescents are visiting the same office or clinic that they came to during childhood, they usually know and feel comfortable with the care providers. This is not the case if it is a first visit.

2. Adolescents most often will readily offer their opinions.

3. If the setting is new to them, explain the procedures and introduce personnel so they feel more at ease.

4. It is important that the adolescent feel welcome, important, and unrushed, in order to gain trust.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-1: Describe the general observations made of adolescents and their families as they come to the pediatric health care home for health supervision visits.

4. An adolescent comes to the clinic because of a concern with a skin lesion, and is accompanied by a parent. When the adolescent is called back to the exam room, the parent comes with the adolescent. What approach by the nurse would be most appropriate?

1. Allow the parent to come into the exam room with the adolescent.

2. Tell the parent she cannot come into the exam room with the adolescent.

3. Instruct the parent to stay in the waiting room and the adolescent will give her a report on the exam.

4. Reassure the parent that you will talk with her about any of her concerns and questions.

Correct Answer: 4 Rationale: 1. The adolescent chooses when the parent comes into the room.

2. The adolescent decides when the parent comes into the room.

3. The adolescent makes the decision about the parent’s presence and whether to report the exam to her.

4. If someone comes with the adolescent, be alert that you might need to provide some private time by asking the other person to wait outside for a moment. Reassure the parent that you will talk with her about any of her concerns and questions, and provide her with an opportunity to ask questions and get information as well.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 14-1: Describe the general observations made of adolescents and their families as they come to the pediatric health care home for health supervision visits.

5. A 17-year-old female presents at a nurse practitioner’s office and requests a signature for work papers. The nurse reviews her chart and notes that the last physical examination was within the year. In addition to providing the signature for the work papers, the nurse should use this visit as: 1. An opportunity to discuss birth control measures.

2. A time to discuss exercise and sports participation.

3. A health supervision opportunity.

4. A chance to discuss the importance of pursuing postsecondary education.

Correct Answer: 3 Rationale: 1. While discussing birth control measures is important, it is only a small portion of the health supervision requirements.

2. Discussing the importance of exercise and sports is important, and should be included in overall health supervision.

3. All visits should be used as health promotion and health supervision opportunities.

4. Discussing future educational plans is important, but these can be included in the overall health supervision protocols.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 14-2: Identify the major health concerns of adolescents.

6. A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. The priority nursing action is to: 1. Call the respective parents to discuss the eating patterns of each adolescent.

2. Speak with the girls in a group to discuss the problems associated with anorexia nervosa.

3. Refer these adolescents to the school psychologist.

4. Obtain a nutritional history for each of these adolescents.

Correct Answer: 4 Rationale: 1. Speaking with the parents would not be appropriate at this time.

2. Discussing anorexia nervosa at this point is too extreme.

3. Referring the adolescents to a school psychologist without performing a complete nursing assessment is not appropriate.

4. The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-2: Identify the major health concerns of adolescents.

7. A nurse is planning to present a lecture/discussion on health maintenance to adolescents in their high school health class. The nurse will include which topic in the presentation information?

1. Limiting refined sugar and high-fat intake 2. Resources for treatment of eating disorders for all adolescents 3. Type 2 diabetes mellitus and insulin resistance 4. The importance of decreasing calcium intake once full adult height is achieved Correct Answer: 1 Rationale: 1. A general presentation should focus on normal expected behaviors for health promotion, such as limiting refined sugar intake and including dairy in the diet.

2. Discussing eating disorders and diabetes mellitus is not appropriate for health promotion activities.

3. Discussing eating disorders and diabetes mellitus is not appropriate for health promotion activities.

4. Decreasing calcium would not be a recommendation for teenagers.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 14-2: Identify the major health concerns of adolescents.

8. A 15-year-old female adolescent’s body mass index (BMI) is 27.5. The adolescent’s height is 5 feet, 2 inches, and she weighs 160 pounds. The girl’s menses began when she was 12 years old.

School performance has been spotty. The priority client teaching would be related to: 1. Nutritional intake.

2. School performance.

3. Adolescent mini mental health status examination.

4. Menstrual cycle.

Correct Answer: 1 1. The BMI for this client is too high, placing the adolescent at risk for cardiovascular disease, hypertension, and diabetes mellitus in later life. Therefore, nutritional intake is the most important topic to focus on with this client at this time.

2. School performance is not as high a priority as the BMI. 3. The mental health screening exam is not as high a priority as the BMI. 4. The menstrual cycle appears to have started at a normal time, and so is not the priority.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-2: Identify the major health concerns of adolescents.

9. An adolescent reports the following: “I get up at 6 a.m., attend early-morning band classes three times each week, play sports for two hours each day after school, and homework takes me three hours each night. I always feel tired.” The priority history question is: 1. How many hours of sleep do you get each night?

2. Do you consume foods high in iron?

3. Do you think you are doing too much?

4. Have you considered talking with your teachers about decreasing your homework?

Correct Answer: 1 Rationale: 1. The data in this scenario reveal very little time for sleep; therefore, the history should focus on sleep patterns.

2. The scenario does not include information about food intake, and low iron might cause the tired feeling described.

3. It is obvious the adolescent is doing too much; however, it is doubtful she would think it excessive.

4. This is inappropriate; the adolescent needs to decrease extracurricular activities, not homework.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-3: Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of adolescents.

10. The school nurse performs screenings on all students in the high school. One student tells the nurse that since starting high school, she is constantly tired and moody. Which of these should the nurse investigate further?

1. Sleep deprivation

2. School adjustment

3. New friends

4. New teachers Correct Answer: 1 Rationale: 1. The effects of sleep deprivation can be serious. Teens cannot perform to their potential in school or at work. Many parents state that adolescents are moody and difficult to communicate with when they are tired.

2. There is no indication that school adjustment has been an issue.

3. No mention of friends is made in the scenario.

4. New teachers would not be a cause for the student to be tired and moody.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Intervention Learning Outcome 6-3: Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of adolescents.

11. During an annual physical, the adolescent reports typical food intake to the nurse. Which requires further assessment by the nurse?

1. “I have a salad for lunch at school.”

2. “I have fried eggs and soda for breakfast.”

3. “I have meat, a vegetable, and rice for dinner.”

4. “I have a piece of fruit for snack.”

Correct Answer: 2 Rationale: 1. Having a salad for lunch at school is not a problem and does not require further assessment.

2. Health maintenance plans center on those practices that prevent disease, including limiting refined sugar and high-fat intake such as soft drinks and fried foods in order to maintain weight at the recommended level.

3. There is no issue with the adolescent having meat, a vegetable, and rice for dinner.

4. Snacking on fruit is healthy, and so requires no additional assessment.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-3: Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of adolescents.

12. The nurse is teaching a class of adolescent students the importance of physical exercise.

Which statement by a student needs further discussion?

1. “I don’t need to exercise. I am healthy, unlike my mother, who has diabetes.”

2. “I walk my dog in the neighborhood for at least 30 minutes daily.”

3. “I ride my bike instead of driving whenever I can.”

4. “I exercise daily because heart disease runs in my family.”

Correct Answer: 1 Rationale: 1. Health maintenance focuses on physical activity as a method to prevent diseases such as cardiovascular disease and diabetes. Youth who have family members with these diseases, or who meet adults who have them, are more likely to understand the importance of their own activity.

2. Walking 30 minutes every day is an appropriate activity.

3. Riding bikes instead of driving is healthy, and requires no further discussion.

4. The adolescent’s comment shows an understanding of how the risk factors for heart disease can be minimized, so this comment requires no further discussion.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-3: Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of adolescents.

13. The nurse is giving a group of adolescents a lecture on sex education. After the lecture, one adolescent asks the nurse for advice regarding being pressured by a boyfriend to have sex. Which response by the nurse is most appropriate?

1. “It’s okay to have sex with your boyfriend if you love him.”

2. “If all your friends are doing it, go ahead and follow your friends.”

3. “Continue with your plan of not having sex right now.”

4. “I can provide you with condoms if you need some.”

Correct Answer: 3 Rationale: 1. It is not appropriate for the nurse to tell a student it is okay to have sex.

2. It is not appropriate to support peer pressure with regard to sex.

3. Provide support for adolescents who have decided not to have sexual intercourse.

Encourage them to continue this plan, telling them that sexual feelings are normal, but that their decision about sexual intercourse is their right and privilege.

4. The adolescent has decided not to have sex, and should be supported in this decision, not offered condoms.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 14-3: Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of adolescents.

14. The nurse is having an informal talk with a group of adolescent at a health fair. Which statement requires follow up by the nurse?

1. “I wish I had a different body.”

2. “I like the way I look, pleasingly plump.”

3. “I can lose a few pounds, according to my doctor.”

4. “I will begin to exercise to stay healthy.”

Correct Answer: 1 Rationale: 1. A healthy image includes the realization that the body has positive and less positive attributes, and that the individual can influence the body through healthy eating and physical activity. Be alert for the teen whose wish for a different body leads to eating disorders and excessive exercise or intake of nutritional supplements.

2. The adolescent who makes this statement does not require follow-up by the nurse.

3. The comment to lose a few pounds does not require follow-up.

4. The nurse would not need to follow up after hearing this comment, as this is healthy.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 14-3: Apply assessment skills to gather data regarding nutrition, physical activity, mental health status, and growth and development of adolescents.

15. A teenager is accompanied by his mother to the annual physical examination. The nurse is aware of privacy issues related to the teenager. While the mother is in the room, which topic should the nurse avoid?

1. School friends 2. Cigarette smoking 3. School performance 4. Seatbelt use Correct Answer: 2 1. The nurse can ask general questions about seatbelt use, academic performance, and school friends without breaching confidentiality.

2. The nurse must maintain the nurse–client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any

personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes.

3. The nurse can ask general questions about seatbelt use, academic performance, and school friends without breaching confidentiality.

4. The nurse can ask general questions about seatbelt use, academic performance, and school friends without breaching confidentiality.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 14-4: Apply therapeutic communication skills with the adolescent and family during health supervision visits.

16. The nurse working in the clinic includes an adolescent history in every client intake interview. Which of these issues should the nurse address when the parents are not present?

1. Possible domestic violence 2. Teen job responsibilities 3. Activities done as a family 4. The adolescent’s role in the family Correct Answer: 1 Rationale: 1. If domestic violence is suspected, it would be appropriate to ask these questions only when the teenager is alone with the nurse or health care provider.

2. Job responsibilities are not confidential, and could be discussed in front of the parents.

3. The activities of the family are not confidential, and could be discussed when the parents are present.

4. The adolescent’s role in the family is not confidential, and could be discussed when the parents are present.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 14-4: Apply therapeutic communication skills with the adolescent and family during health supervision visits.

17. An obese adolescent who adamantly denies sexual activity has a positive pregnancy test.

Which of the following statements would be most appropriate for the nurse to make to this adolescent?

1. “Tell me how you feel about your body image.”

2. “When was your last menstrual period (LMP)?”

3. “Let’s discuss some activities that you have done within the past few months that could possibly lead to pregnancy.”

4. “Why are you denying sexual intercourse?”

Correct Answer: 3 Rationale: 1. The adolescent’s body image does not address the teen’s current situation.

2. Asking about the LMP does not help connect the adolescent’s past behavior to her pregnancy.

3. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is to ask a direct question in which the nurse and client search for an answer.

4. This option is too confrontational, and may alienate the adolescent.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 14-4: Apply therapeutic communication skills with the adolescent and family during health supervision visits.

18. A mother reports that her adolescent daughter is always late. The mother states, “She was born late, and has been late every day of her life.” Which response should the nurse make to this mother?

1. “You need to establish specific time frames for your adolescent and be certain she adheres to them.”

2. “Setting specific alarms and then reinforce the value of being ‘on-time’ may be helpful strategies to assisting her to be more of an ‘on-time’ individual.”

3. “Just let it go for now. Teachers and, in the future, employers will be the best people to help her be ‘on-time’.”

4. “You have a major problem. There must be a lot of screaming in your home.”

Correct Answer: 2 Rationale: 1. The nurse who tells the mother to establish time frames is making the assumption this is not already the case in the household.

2. The best response is to help the mother find a way to help the teen deal with the problem of lateness.

3. It is not appropriate for the nurse to advise the mother to do nothing. The parents are the ones responsible for changing their child’s behavior.

4. This answer choice makes assumptions about the household communication in which the parent and adolescent live.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 14-4: Apply therapeutic communication skills with the adolescent and family during health supervision visits.

19. The school nurse performs screenings on all students in the high school. In addition, the nurse will perform selected screenings on individual teenagers. When planning the screenings for the year, the nurse will include which screening for all teenagers?

1. Scoliosis 2. Hepatitis B profile 3. Respiratory rate 4.

Chest x-ray

Correct Answer: 1 Rationale: 1. Routine screening for adolescents includes checking for scoliosis, height, and weight, and blood pressure measurements.

2. The hepatitis B profile is needed only once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all adolescents.

3. A respiratory rate is not a screening exam for all adolescents. It is done throughout childhood at each health supervision visit.

4. A chest x-ray is not a routine screening test for adolescents.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 14-5: Intervene with adolescents and their families to integrate activities to promote health and to prevent disease and injury.

20. A nursing history on a 17-year-old female reveals that the adolescent takes a multivitamin with 0.5 mg of fluoride each day and one with 0.4 mg of folic acid each day. What concern should the nurse bring to the attention of the physician?

1. The presence of fluoride in the multivitamin 2. The amount of fluoride in the multivitamin; it should be increased to 1.0 mg each day.

3. The intake of folic acid 4. The need for a daily iron tablet Correct Answer: 1 Rationale: 1. Fluoride supplementation is not recommended for teenagers over the age of 16.

2. Fluoride supplementation is not recommended for teenagers over the age of 16.

3. Folic acid is recommended for all women of childbearing age to prevent neural tube defects.

4. There are no data to support iron recommendations for the client in this scenario.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 14-5: Intervene with adolescents and their families to integrate activities to promote health and to prevent disease and injury.

21. An adolescent who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: “I have no friends in my new school, and I no longer want to go to college. I know I will be lonely there, too.” Which of the following takes priority when speaking with the adolescent?

1. Helping the adolescent realize the value of postsecondary education 2. Promoting healthy mental health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school due to adolescent exclusion behaviors 4. Stressing the importance of remaining in a close parent–child relationship during these stressful times Correct Answer: 2 Rationale:

1. It would not be appropriate to discuss the importance of a college education at this time, since the adolescent must deal with the loss of friends and with developing new friends first.

2. The adolescent is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental health outcomes for the child.

3. It would be more upsetting to the adolescent if the nurse made this comment.

4. The parent–child relationship should not be used as a substitute for the development of new peer relationships.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 14-5: Intervene with adolescents and their families to integrate activities to promote health and to prevent disease and injury.

22. An adolescent reports participating in an exercise program at school each Wednesday throughout the school year. Further history reveals that the adolescent does not participate in any other physical activities. Which of these outcomes is consistent with these data?

1. The adolescent is reporting information consistent with what 60% of adolescents report as participation in physical activities.

2. The adolescent is not meeting the recommendations of the Healthy People 2010 initiative.

3. The adolescent should be encouraged to continue this program of exercise, since something is better than nothing.

4. The adolescent should be encouraged to vigorously exercise for at least five minutes each day.

Correct Answer: 2 Rationale:

1. There is inadequate information in this scenario to choose this answer option.

2. In this scenario, the adolescent is not receiving the recommended amount of exercise to support good health habits.

3. Suggesting that “something is better than nothing” is not good practice.

4. Encouraging the adolescent to continue as is or to exercise vigorously for five minutes each day also is not consistent with current recommendations.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 14-5: Intervene with adolescents and their families to integrate activities to promote health and to prevent disease and injury.

23. The nurse has just completed a thorough assessment of an adolescent in the clinic who has begun dating and is now withdrawn. Which diagnosis is appropriate for the adolescent and family?

1. Rape-Trauma Syndrome related to date rape 2. Balanced Nutrition: adequate body requirement 3. High Self-Esteem related to good friends 4. Adequate Sleep Pattern related to adequate sleep schedule Correct Answer: 1 Rationale: 1. A wide array of health concerns should be included in the assessment of adolescent. Based on a thorough assessment, you will establish nursing diagnoses that are appropriate for the adolescent and family. One possible nursing diagnosis might be Rape-Trauma Syndrome related to date rape for the teen who has recently begun dating and now is withdrawn.

2. There is no inclusion of nutrition information in this scenario.

3. Withdrawal is not an indication of high self-esteem and good friendships.

4. There is no indication of sleep pattern in this scenario.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Diagnosis Learning Outcome 14-6: Synthesize data from history and examination of adolescent and family with knowledge of adolescent development to plan approaches useful with the family during health supervision encounters.

24. The nurse is speaking with a group of adolescents about what can happen when having unprotected sex. The nurse understands that to communicate effectively with teens, she must: 1. Allow for discussion, and bring peers who have had experience related to the topic being discussed.

2. Lecture on the topic for the allotted time without any discussion.

3. Offer personal opinions on the topic, and cite examples of what can happen if they don’t listen.

4. Discuss sex education related to religious belief.

Correct Answer: 1 Rationale: 1. Whatever the setting, the nurse partners with the adolescent, the parents, and other persons such as teachers or school counselors to plan appropriate goals and related intervention. Apply communication skills effective with teens, such as listening to concerns, allowing for discussion, and bringing peers who have had experiences related to the topic being discussed.

2. Lecturing without discussion will not draw in the adolescent to the content.

3. Personal opinions will not carry much weight with a group of adolescents.

4. Discussing sex education from a religious viewpoint is not appropriate.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning

Learning Outcome 14-6: Synthesize data from history and examination of adolescent and family with knowledge of adolescent development to plan approaches useful with the family during health supervision encounters.

25. What would be the best way for the nurse to teach adolescents regarding health promotion and health maintenance?

1. Have the adolescents identify a personal health goal.

2. Tell the adolescents what you will lecture on.

3. Ask the advice of the counselors at school.

4. Contact the parents and ask what issues they have with their adolescents.

Correct Answer: 1 Rationale: 1. Teaching topics will be directed at both health promotion and health maintenance. A good starting point is to have the adolescent identify a personal health goal, and begin teaching there.

2. Lecturing an adolescent group is not as effective as is having an honest and open discussion with adequate time for questions.

3. It is not necessary for the nurse to ask the counselors at school for advice on health topics.

4. Talking to the parents first is not necessary. The same issues arise for adolescents, and should be discussed in general, and not according to specific individuals.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 14-6: Synthesize data from history and examination of adolescent and family with knowledge of adolescent development to plan approaches useful with the family during health supervision encounters.

1. Prior to accepting an assignment as a home health nurse, the nurse must realize that: 1. All decisions will be made by the health care provider.

2. The family will adapt their lifestyle to the needs of the nurse.

3. Independent decisions regarding emergency care of the child will be made by the nurse.

4. The family is in charge.

Correct Answer: 4 Rationale: 1. All decisions will be made by the family, not by the health care provider.

2. The nurse must be flexible and adaptable to the lifestyle of the family, not the other way around.

3. The family must provide informed consent for emergency care.

4. The home health nurse must realize that the family is in charge.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-1: List the types of community health care settings where the nurse provides health services to children.

2. Children receive most of their health care in community settings. Which is an example of nursing care provided in a community setting?

1. Surgery and diagnostic testing procedures in ambulatory surgical settings 2. Episodic health care for chronic illnesses 3. Care of children in an emergency setting 4. Care of children needing care in an ICU setting

Correct Answer: 1 Rationale: 1. The nursing role is important in promoting children’s health in the community. The range of nursing care provided is quite broad. Examples of nursing care provided in community settings include surgery and diagnostic testing procedures in ambulatory surgical settings.

2. Episodic care for chronic illnesses ordinarily occurs in the pediatric health care home, not in the community setting.

3. The emergency care setting is not considered a community setting.

4. The care received in an ICU setting is not considered a community setting.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-1: List the types of community health care settings where the nurse provides health services to children.

3. Which is an appropriate function for the pediatric nurse to assume in an office or health center?

1. Identifying children in need of urgent care or isolation 2. Performing minor surgical procedures 3. Providing medical care to chronically ill children 4. Performing major surgical procedures Correct Answer: 1 Rationale:

1. The nursing process is used when providing care for children in the health center, and in some cases in the mobile health van. The range of assessment responsibilities can vary by setting, as can the preparation and experience of the nurse. Specific functions of the pediatric nurse in this setting include identifying children in need of urgent care or isolation.

2. Nurses do not perform minor surgical procedures, regardless of location.

3. The nurse could provide nursing care, not medical care, to chronically ill children.

4. Nurses do not perform major surgical procedures, regardless of location.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-1: List the types of community health care settings where the nurse provides health services to children.

4. The role of the nurse in the school setting can include: 1. Providing medical diagnoses for children with illnesses.

2. Providing health assessment of infants of mothers enrolled in school.

3. Providing medication to children when requested without prescription.

4. Providing mental health therapy upon request.

Correct Answer: 2 Rationale: 1. Establishing medical diagnoses is not within the realm of the registered professional nurse.

2. Nursing roles in the school setting focus on promoting the health and safety to the population of children enrolled, and providing direct care to ill and injured children. Children in the school setting can include infants if childcare is offered for adolescent mothers, as well as preschool-age children attending Head Start.

3. Nurses cannot provide medication, usually even over-the-counter medications, to children without prescription and written permission of the parent or guardian.

4. Nurses might suggest that a child obtain mental health therapy, but would not provide the therapy even upon request.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 15-1: List the types of community health care settings where nurse provide health services to children

5. A child is being discharged after an extended hospitalization. Prior to discharge from a hospital, home health care nurses should assess which aspect of the home setting?

1. Readiness of the home for the discharged patient 2. Parents’ income 3. Parents’ home location Parents’ insurance 4.

Correct Answer: 1 Rationale: 1. When working with the hospital discharge planner to initiate home health care services, the nurse should assess the home readiness (safe sleeping arrangements, adequate supplies, ability to meet nutritional and fluid needs, telephone access, heat, electricity, refrigeration, lack of communicable disease in the home, and safe access into and out of the home).

2. The nurse would not assess the income of the parents. Social workers might assist in this arena.

3. The home location is assessed only insofar as determining whether heat, electricity, water, and the necessary services are available in the location.

4. The nurse would not assess the parent’s insurance. Social workers might assist the parents in this area.

Cognitive Level: Evaluation Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-1: List the types of community health care settings where nurse provide health services to children.

6. A 16-year-old client has a long leg cast secondary to a fractured femur. To effectively facilitate the adolescent’s return to school, the school nurse should: 1. Meet with teachers and administrators at the school to make sure that entrances and classrooms are wheelchair-accessible.

2. Develop an individualized health plan (IHP) focusing on long-term needs of the adolescent.

3. Meet with all of the other students prior to the student’s return to school to emphasize the special needs of the injured teen.

4.

Meet with parents of the injured student to encourage homebound schooling until a

short leg cast is applied.

Correct Answer: 1 Rationale: 1. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair-accessible prior to the adolescent’s return to school.

2. While an IHP might be developed, short-term needs would be the focus.

3. It is not necessary to meet all of the students to discuss the adolescent’s needs.

4. There is no reason to encourage the child to stay at home for schooling if he is ready to return.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 15-2: Describe the role of the nurse in each identified community health care setting.

7. The community health nurse is planning an education session for recently hired teachers at a child-care center. It is most important that the nurse teach the staff: 1. The schedule for immunizations.

2. Principles of infection control.

3. How to interpret health care records.

4. How to take a temperature.

Correct Answer: 2 Rationale: 1. The schedule of immunizations is important for child-care administrators to know, but it is not most important for teachers to know this information.

2. While all of the information is nice to know, it is most essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children.

3. Health care records are important for child-care administrators to interpret to ensure compliance with state regulations, but not more important to know than are principles of

infection control.

4. It is important for the child-care teacher to know how to take a temperature, but it is a higher priority for the teacher to know how to maintain infection control.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-2: Describe the role of the nurse in each identified community health care setting.

8. Prior to her return to school, an individualized health plan (IHP) will be developed for the child who has: 1. Recently developed a penicillin allergy.

2. Been newly diagnosed with insulin-dependent diabetes mellitus.

3. Been treated for head lice.

4. Missed two weeks of school due to mononucleosis.

Correct Answer: 2 Rationale: 1. A child who is allergic to penicillin will not receive this medication any longer, and therefore should not encounter any problems related to it at school.

2. An IHP that ensures appropriate management of the child’s health care needs must be developed for a child newly diagnosed with a chronic illness such as diabetes.

3. A child who has been treated for head lice can return to school, and does not need an IHP. 4. While a child who has missed two weeks of school will need to make arrangements for makeup work, an IHP is not needed.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-2: Describe the role of the nurse in each identified community health care setting.

9. A child with a history of asthma is actively wheezing. Which is the best initial action by the nurse?

1. Call 911 to request emergency medical assistance.

2. Call the child’s parents to come and pick up the child.

3. Have the child use his metered-dose inhaler.

4. Have the child lie down to see if the symptoms subside.

Correct Answer: 3 Rationale: 1. Emergency personnel should be notified if the inhaler does not provide relief and the child is in respiratory distress.

2. Parents may be notified if the child does not feel well, but this is not the initial action.

3. A child with a history of asthma might have episodes of wheezing that can be controlled by prompt use of the child’s rescue inhaler. An inhaler should be readily available in the school setting for a child previously diagnosed with asthma. This should be tried first.

4. Having the child lie down likely will worsen his condition.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 15-2: Describe the role of the nurse in each identified community health care setting.

10. The telephone triage nurse receives a call from a parent who states that her 18-month-old is making a crowing sound when he breathes and is hard to wake up. Which is the nurse’s priority action?

1. Obtain the history of the illness from the parent.

2. Advise the parent to hang up and call 911.

3. Make an appointment for the child to see the health care provider.

4. Reassure the parent and provide instructions on home care for the child.

Correct Answer: 2 Rationale: 1. Obtaining the history is appropriate only after the child has received emergency treatment to control the airway.

2. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 911. Crowing is heard when there is severe narrowing of the airway.

3. Making an appointment would be appropriate in non-emergency situations.

4. Home care is not appropriate, as a crowing sound at rest with a change in the level of consciousness makes this an emergency situation for 911.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 15-2: Describe the role of the nurse in each identified community health care setting.

11. The number of serious injuries of children in a community has doubled in the past year.

Based on this information, the most appropriate community nursing diagnosis is:

1. Noncompliance related to inappropriate use of child safety seats.

2. Injury, risk for related to inadequate use of bicycle helmets.

3. Altered Family Processes related to hospitalization of an injured child.

4. Knowledge, Deficient related to injury prevention in children.

Correct Answer: 4 Rationale: 1. The incorrect use or non-use of child safety seats and non-use of bicycle helmets might be the appropriate diagnosis in specific situations, but the broader knowledge deficit is the most appropriate choice.

2. The incorrect use or non-use of child safety seats and non-use of bicycle helmets might be the appropriate diagnosis in specific situations, but the broader knowledge deficit is the most appropriate choice.

3. Based on the doubled injury rate, the most appropriate nursing diagnosis addresses the reason behind the increase in serious injuries, not the hospitalizations that occur afterward.

4. Knowledge Deficient related to injury prevention in children is the only diagnosis that is general to the problem as a whole, and is therefore the most appropriate community nursing diagnosis.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Diagnosis Learning Outcome 15-3: Outline the steps of a family-centered assessment for the child and family in a community setting, and develop a nursing care plan that promotes the health of the child.

12. Which should the nurse take into consideration when working with families in a home?

1. Family member preferences for involvement in the care of the child

2. The size of the child’s room for therapy 3. Ensuring that both parents participate in the care of the child 4.

Training all members of the family to take part in the child’s care

Correct Answer: 1 Rationale: 1. When working with families in the home, make sure that house rules are negotiated. Be sure to discuss guidelines for the expected behavior and role of the nurse, as well as the family’s preferences for involvement in the care of the child.

2. The size of the child’s room has no bearing on the child’s care as given by the family members.

3. It is not necessary for both parents to participate in the care of the child. It must be an individual family’s decision based on what is best for the family and the particular child.

4. Training all members to particpate in the care of the child might be inappropriate based each member’s age, abilities, and deverlopmental stage.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 15-3: Outline the steps of a family-centered assessment for the child and family in a community setting, and develop a nursing care plan that promotes the health of the child.

13. When a child is returning to school after an absence and needs medication or other therapies during school hours, who should be involved in the child’s health plan?

1. Physician 2. Minister 3. School administrators

4. Siblings Correct Answer: 3 Rationale: 1. During school hours, the physician does not need to be involved in the child’s health plan.

2. The child or family’s minister does not need to be involved in the child’s health plan during school hours.

3. Because some children need medications or other therapies during school hours, the parents and child, school nurse, teachers, and school administrators develop a plan to manage the child’s condition during school hours. This document is the child’s individualized health plan.

4. During school hours, it is not appropriate or necessary for siblings to be involved in the child’s health plan.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-3: Outline the steps of a family-centered assessment for the child and family in a community setting, and develop a nursing care plan that promotes the health of the child.

14. Which role would the school nurse least likely pursue?

1. Assisting children with chronic conditions to have health care needs met 2. Performing essential skilled nursing tasks for children with special medical needs 3. Supervising unlicensed assistive personnel in the health office 4. Providing referrals to students because of tardiness to school Correct Answer: 4

Rationale: 1. Previously homebound children who are medically fragile and need skilled nursing care with or without medical equipment to support vital functions now attend school. Outcomes of school nursing care include students with chronic conditions have their health care needs met.

2. Previously home bound children who are medically fragile and need skilled nursing care with or without medical equipment to support vital functions now attend school. Outcomes of school nursing care include students with chronic conditions have their health care needs met.

3. The school nurse also is responsible for the supervision of unlicensed assistive personnel in the health office.

4. It is outside the nurse’s responsibility to involve herself in the students’ getting to school on time.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-3: Outline the steps of a family-centered assessment for the child and family in a community setting, and develop a nursing care plan that promotes the health of the child.

15. The school nurse is seeing a 5-year-old child who requires oxygen and tube-feeding. The nurse evaluates the child as: 1. Mentally handicapped.

2. Medically fragile.

3. Developmentally delayed.

4. No special care needed.

Correct Answer: 2 Rationale: 1. There is no indication that this 5 year-old is cognitively delayed. The words “mentally handicapped” are no longer considered appropriate descriptors of children who are cognitively delayed.

2. A child who is dependent on medical devices or supplies for survival or prevention of further disability is medically fragile.

3. There is no indication that this child is not developing at a normal pace.

4. Special care is needed for this child, as oxygen and tube feedings are required.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 15-3: Outline the steps of a family-centered assessment for the child and family in a community setting, and develop a nursing care plan that promotes the health of the child.

16. Specific functions of the pediatric nurse in primary care include which task(s)?

1. Assisting with physician examinations and performing diagnostic tests 2. Developing medical diagnoses and implementing a plan of care 3. Conducting medical examinations 4. Prescribing medication for the children Correct Answer: 1 Rationale:

1. Nurses use the nursing process when providing care for children in the primary care setting.

The range of assessment responsibilities can vary by setting, as well as according to the preparation and experience of the nurse. Specific functions of the pediatric nurse in primary care include assisting with physician examination and performing diagnostic tests.

2. The pediatric nurse does not develop medical diagnoses or a plan of care.

3. The nurse does not conduct medical examinations, but rather a nursing assessment.

4. The nurse does not prescribe medication for children.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 15-4: Describe the potential roles of the pediatric nurse or school nurse in supporting a community assessment process.

17. An important goal for pediatric nurses in the office or health care setting is: 1. Develop a positive relationship with the child and family.

2. Tell the family immediately what’s wrong with the child.

3. Tell the family “Everything will be okay.”

4. Develop a plan of care with the physician for the family.

Correct Answer: 1 Rationale: 1. An important goal for nurses in the office or health care setting is to develop a positive partnership with the child and family so that optimal health care is provided. The relationship with the family grows over the months and years of providing care to the child and family.

2. The nurse might not be able to tell the family what is wrong with the child.

3. This is not therapeutic communication, as the nurse cannot guarantee that “everything will be okay”.

4. The nurse does not develop a plan for medical care, with or without the physician.

Cognitive Level: Analysis Client Need: Save, Effective Care Environment Nursing Process: Implementation Learning Outcome 15-4: Describe the potential roles of the pediatric nurse or school nurse in supporting a community assessment process.

18. Camp nurses can function: 1. Dependently.

2. Independently.

3. Internally.

4. Remotely.

Correct Answer: 2 Rationale: 1. As the camp nurse sometimes is working alone as the only care provider, it is essential for the nurse to have the ability to work independently.

2. Nurses in camps function independently and need to use critical thinking skills, much like school nurses.

3. The camp nurse would function wherever he was needed, regardless of location within the camp.

4. Whether the camp is in remote areas or well populated areas, the camp nurse must be able to function independently, as often the camp nurse is the only health care provider at the camp.Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 15-4: Describe the potential roles of the pediatric nurse or school nurse in supporting a community assessment process.

19. A major goal of home health care nurses working with families is: 1. Promoting or restoring the child’s health.

2. Maximizing the dependency of the child on the family.

3. Curing the chronic illness of the child.

4. Prescribing and administering medication needed by the child.

Correct Answer: 1 Rationale: 1. A major goal of working with families in the home health care setting includes promoting or restoring the child’s health while attempting to minimize the effects of the disability and illness, including terminal illness.

2. The home health care nurse would not want to ensure that the child stays dependent on the family, but rather that she learns to function as independently as possible.

3. The nurse’s role in home health care is to provide nursing care for the child, not to cure the chronic illness the child has.

4. The nurse might assist in medication administration for the child, but would not prescribe the needed medication.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-4: Describe the potential roles of the pediatric nurse or school in supporting a community assessment process.

20. A child who is dependent on a ventilator is being discharged from the hospital. Prior to discharge, the home health nurse discusses development of an emergency plan of care with the family. Which is the most essential part of the plan?

1. Acquisition of a backup generator 2. Designation of an emergency shelter site 3. Provision for an alternate heating source if power is lost 4.

Notifying the power company that the child is on life support

Correct Answer: 1 Rationale: 1. Prior to discharge to home, it is essential that the family acquire a generator so that the child’s life support will continue to function effectively should power be lost. While all other actions are very important, it is most essential that the ventilator has power to continue to function at all times.

2. This designation might be necessary should power remain off for an extended period, but it is more important for the family to obtain a backup generator.

3. A secondary heat source is secondary to acquiring alternative power for the ventilator.

4. Notifying the power company is secondary to acquiring alternative power for the ventilator.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Planning Learning Outcome 15-5: Describe the special needs of children that should be considered in disaster preparedness.

21. Which aspect of an Emergency Medical Services system is most indicative that EMS providers are prepared to provide emergency care to children?

1. Placement of small stretchers in emergency vehicles 2. Lists of hospitals in the area that treat children 3. Staff education related to assessment and treatment of children of all ages 4. Pediatric-size equipment and supplies Correct Answer. 3 Rationale: 1. The stretcher size would not necessarily change to transport a child; the addition of car seat might be more indicative of preparedness.

2. Having lists of hospitals treating children is important, but having education for EMS providers is even more indicative of preparedness.

3. The aspect most indicative that EMS providers are actually prepared to take care of children is evidence of education related to assessment and emergency treatment.

4. Size-appropriate equipment for children is an essential part of an EMS system, but is less important than is knowing how to use the equipment and assess children.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Evaluation Learning Outcome 15-5: Describe the special needs of children that should be considered in disaster preparedness.

22. Which of the following should be considered in disaster preparedness for children with special needs?

1. The utility company needs advance notification when a child is technology-assisted, to provide emergency power.

2. Minimal supply of medication, equipment, and supplies should be maintained.

3. Only one family member should be trained to provide the needed care, for the sake of consistency.

4. Current medical information should only be maintained by the child’s health care provider.

Correct Answer: 1 Rationale: 1. Planning is important when a family has a child with chronic health condition or one who is technology-assisted. The utility company needs advance notification when a child is technologyassisted to provide emergency power as quickly as possible.

2. Several days’ worth of medications and supplies should be maintained at all times.

3. Each family member who has the ability and willingness to learn should be trained to provide the needed care should something happen to incapacitate the primary caregiver.

4. In case of a disaster, the child’s health care provider may not be accessible. It is important for the family as well as community agencies to have medical information about children with special needs.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 15-5: Describe the special needs of children that should be considered in

disaster preparedness.

23. Which of the following should the nurse encourage families to include when developing a disaster plan?

1. Having an adequate supply of medication, equipment, and supplies 2. Understand that there is no need to anticipate a disruption of service.

3. There is no need to make arrangement for pets.

4.

Only one family member should be trained to provide the needed care, for the sake of

consistency.

Correct Answer: 1 Rationale: 1. Additional planning is important when a family has a child with a chronic health condition or one who is technology-assisted. An adequate supply of medication, equipment, and supplies should be maintained at all times. Resources to obtain a refill of medication and needed supplies during a disaster should be identified.

2. The family should anticipate several days’ disruption in service during a disaster, and plan accordingly.

3. Pets should be a part of the disaster plan, including food, water, and any necessary medications.

4. More than one family member should be trained to provide needed care for a chronically ill or special needs child during a disaster, or in case something should happen to the primary caregiver.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning

Learning Outcome 15-5: Describe the special needs of children that should be considered in disaster preparedness.

1. A group of children on one hospital unit are all suffering separation anxiety. When determining the stages of separation anxiety, the nurse recognizes that the child in the “despair” phase is the child who: 1. Does not cry if his parents return and leave again.

2. Screams and cries when his parents leave.

3. Appears to be happy and content with staff.

4.

Lies quietly in bed.

Correct Answer: 4 Rationale: 1. The young child who appears to be happy and content with everyone is in the “denial” stage, as is the child who does not cry if his parents return and leave again.

2. Screaming and crying are components of the “protest” stage.

3. The young child who appears to be happy and content with everyone is in the “denial” stage, as is the child who does not cry if his parents return and leave again.

4. Children in the “despair” stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. .

Cognitive Level: Application

Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 16-1: Discuss the child’s understanding of health and illness according to the child’s developmental level.

2. In addition to separation anxiety, infants between 6 and 18 months of age also might display:

1. Disfigurement.

2. Stranger anxiety.

3. Bodily injury.

4. Fear of death.

Correct Answer: 2 Rationale: 1. Infants do not fear disfigurement.

2. In addition to separation anxiety, infants between 6 and 18 months of age might display stranger anxiety when confronted with strangers such as health care professionals.

3. Infants and toddlers do not fear bodily injury.

4. Infants and toddlers do not fear death.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 16-1: Discuss the child’s understanding of health and illness according to the child’s developmental level.

3. At which stage are children at greatest risk for a stressful experience as a result of illness and hospitalizations?

1. Infant

2. Toddler 3. Preschool 4. School-age Correct answer: 2 Rationale: 1. Infants are not at greatest risk from hospitalizations as long as they have their needs met.

2. Toddlers are the group at greatest risk for a stressful experience as a result of illness and hospitalization. This age group is old enough to understand that their routine has been disrupted, but they lack the cognitive ability to understand why.

3. Preschool-age children are old enough to understand more of why their routine is disrupted, and that they did not misbehave to cause their illness or hospitalization.

4. School-age children are the most likely to understand why their routine is disrupted, and that their illness has nothing to do anything they might have done.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 16-1: Discuss the child’s understanding of health and illness according to the child’s developmental level.

4. When preschoolers are hospitalized, and parent cannot stay with them, when would be an inappropriate time for the parents to leave the hospital?

1. After the child has dinner 2. When the parents are tired 3. After the child has fallen asleep 4. When visiting hours have ended

Correct answer: 3 Rationale: 1. After the child has had dinner is an appropriate time for the parent to leave the child.

2. The parents are appropriate if they leave when they are tired.

3. Parents often believe that leaving while their children are asleep is better for their children. In actuality, when children do not expect their parents to be absent and they awaken to find their parents gone, they become anxious, and might even develop a lack of trust.

4. It is appropriate to leave when visiting hours are over.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 16-2: Discuss the effects of and response to illness and hospitalization on children and their families.

5. What development stage is the sense of industry?

1. Adolescent 2. Preschool 3. School-age 4. Toddler Correct Answer: 3 Rationale: 1. The adolescent is past the stage of industry, and is working through identity vs. role confusion.

2. Preschool-aged children are working through the stage of initiative vs. guilt.

3. The school-age child has achieved a sense of industry, allowing her to participate in her care as much as possible.

4. Toddlers are working through the developmental stage of autonomy vs. shame and doubt as they learn to do more tasks independently.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 16-2: Discuss the effects of and response to illness and hospitalization on children and their families.

6. When a child is hospitalized, parents have unique needs and stressors. One of the needs is: 1. The need to be seen as a competent parent.

2. The need not to be informed.

3. The need not to have control.

4. The need to have minimal outside support.

Correct answer: 1 Rationale: 1. Parents have unique needs and stressors. Nurses should individualize care based on these specific needs.

2. Needs that are frequently identified by parents of hospitalized children include the need to be informed.

3. Parents need to feel as if they are still in control of their child’s decisions.

4. Parents need to have outside support when a child has been hospitalized.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Application

Learning Outcome 16-2: Discuss the effects of and response to illness and hospitalization on children and their families.

7. The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. The nurse should: 1. Escort the parents to the waiting room and assure them that they can see their child soon.

2. Allow the parents to stay with the child.

3. Ask the physician if the parents can stay with the child.

4. Tell the parents that they do not need to stay with the child.

Correct answer: 2 Rationale: 1. Parents should be allowed to stay with their child if they wish, instead of going to the waiting room, where they lack privacy.

2. Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association, and is a key aspect of family-centered care.

3. The physician does not make the decision whether the parents stay with the child; the parents make the decision.

4. The parents need to make the decision about staying with their child without input from the nurse.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation

Learning Outcome 16-3: Discuss the child and family’s adaptation to hospitalization.

8. The charge nurse on a hospital unit is developing plans of care related to separation anxiety.

The charge nurse recognizes that the hospitalized child at greatest risk to experience separation anxiety when parents cannot stay is the: 1. 6-month-old.

2. 18-month-old.

3. 3-year-old.

4. 4-year-old.

Correct answer: 2 Rationale: 1. The 6-month-old does not experience separation anxiety. It usually begins at around 1 year of age.

2. The young toddler is at greatest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly.

3. The 3-year-old is past the age when separation anxiety would be most prevalent.

4. The 4-year-old is past the age when separation anxiety would be most prevalent.

Cognitive Level: Application

Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 16-3: Discuss the child and family’s adaptation to hospitalization.

9. A 4-year-old is seen in the clinic for a sore throat. In the child’s mind, the most likely causative agent is that the child: 1. Was exposed to someone else with a sore throat.

2. Did not eat the right foods.

3. Yelled at his brother.

4. Did not take his vitamins.

Correct answer: 3 Rationale: 1. This age child does not yet understand that he can become sick from exposure to someone else who is sick.

2. Not eating the right foods can be a factor in some illnesses, but this thinking is beyond the level of a 4-year-old.

3. Preschoolers understand some aspects of being sick, but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They frequently will view illness as punishment.

4. While not taking his vitamins can be a factor in some illnesses, this thinking is beyond the capabilities of a 4-year-old.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 16-3: Discuss the child and family’s adaptation to hospitalization.

10. The charge nurse is concerned with reducing the stressors of hospitalization. The nursing intervention most helpful in decreasing the stressors for the toddler is to: 1. Assign the same nurse to the toddler as much as possible.

2. Let the child listen to an audiotape of the mother’s voice.

3. Place a picture of the family at the bedside.

4. Encourage a parent to stay with the child.

Correct Answer: 4

Rationale: 1. Assigning the same nurse will decrease the toddler’s stress, but not as much as will having a parent stay with the child.

2. Listening to the mother’s voice can relieve stress for a toddler, but having the parent stay will be even more effective.

3. Being able to see the family in a picture can relieve some stress in a hospitalized toddler, but having a parent stay with the child is even more effective.

4. While all of the interventions are appropriate for the hospitalized toddler, the presence of a parent is most important. Separation from parents is the major stressor for the hospitalized toddler.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-3: Discuss the child and family’s adaptation to hospitalization.

11. A 5-year-old is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. The nurse should: 1. Reschedule the treatment for a later time.

2. Show the respiratory therapist to the playroom so the treatment can be performed.

3. Escort the child to his room, and ask the child life specialist to bring toys to the bedside.

4. Assist the child back to his room for the treatment but reassure him that he may return when the procedure is completed.

Correct Answer: 4 Rationale: 1. Scheduled respiratory treatments should be performed on time.

2. Procedures should not be performed in the playroom.

3. The child should be allowed to return to the playroom as soon as the procedure is completed so child life’s bringing toys to the bedside is unnecessary.

4. It is important for scheduled treatments to occur on time, so the child should go back to his room. He can go back to the playroom as soon as the treatment is completed.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-3: Discuss the child and family’s adaptation to hospitalization.

12. A 5-year-old child is admitted to the pediatric unit for surgery. The parents request to stay with their child. Which of the following is the best response by the nurse?

1. Explain to the parents why they cannot stay with the child.

2. Tell the parents they can stay in the hospital but not on the unit.

3. Let the parents know they are allowed to stay with the child.

4. Read the rules and regulations of rooming in with the child.

Correct answer: 3 Rationale: 1. The parents should be allowed to stay with their child.

2. The parents should be allowed to stay with their child on the unit.

3. The practice of rooming in involves a parent’s staying in the child’s hospital room during the course of the child’s hospitalization. Some hospitals provide cots, while others have special built-in beds on pediatric units.

4. The parents should be aware of the rules about rooming in, but they should know first that they can stay.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-4: Apply family-centered care principles to the hospital setting.

13. A child is being prepared for surgery. The parent requests to be present during anesthesia induction. How should the nurse response?

1. The nurse should explain the expectations of the parent when present during induction.

2. The nurse should tell the parent he will be upset to see his child under anesthesia.

3. The nurse should ignore the request and focus on the child.

4. The nurse should tell the parent the names of all the medications the child will receive.

Correct answer: 1 Rationale: 1. The nurse explains expectations, such as surgical gown, cap, shoe covers, and the parent’s role in presence during induction. The nurse offers the parents an opportunity to ask questions and voice concerns.

2. The nurse should tell the parent what to expect, but not how he will feel while he watches his child.

3. The nurse should never ignore a request made by a parent.

4. The parent does not need to know the names of the medications the child will receive.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-4: Apply family-centered care principles to the hospital setting.

14. The nurse is taking care of a child in the ICU. The parent appears very angry, and tells the nurse no one is giving her information about her child. How should the nurse respond?

1. Tell the parent he will ask the doctor to come and talk with her.

2. Inform the parent she will be asked to leave if she continues this behavior.

3. Tell the parent her behavior will upset the patient.

4. Inform the parent of any change in the child’s condition in a timely manner.

Correct answer: 4 Rationale: 1. The parent is already angry because of the lack of information sharing. The nurse should not “pass the buck” to the physician.

2. Telling the parent she will be asked to leave will only worsen the situation.

3. The parent is already angry, and informing her that her behavior will upset the child will only anger her more.

4. Nursing techniques include informing the family of potential problems that could occur. If the child’s condition changes, make every effort to inform the family immediately.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-4: Apply family-centered care principles to the hospital setting.

15. The nurse is caring for a client in the pediatric intensive care unit. The parents have expressed anger over the nursing care their child is receiving. The nursing intervention most appropriate for these parents would be to: 1. Ask the physician to talk with the family.

2. Explain to the parents that their anger is affecting their child, so they will not be allowed to visit the child until they calm down.

3. Acknowledge the parents’ concerns and collaborate with them regarding the care of their child.

4. Call the chaplain to sit with the family.

Correct answer: 3 Rationale: 1. Calling the physician might be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust.

2. Telling the parents that they cannot visit their child will only increase their anger.

3. Hospitalization of the child in a pediatric intensive care unit is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they might become angry and upset.

4. Calling the chaplain could be appropriate at some point, but the nurse needs to collaborate with the parents about the care the child receives.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-5: Identify nursing strategies to minimize the stressors related to hospitalization.

16. The nurse must perform a procedure on a toddler. The technique most appropriate when performing the procedure is to: 1. Ask the mother to restrain the child during the procedure.

2. Ask the child if it is okay to start the procedure.

3. Perform the procedure in the child’s hospital bed.

4. Allow the child to cry or scream.

Correct answer: 4 Rationale: 1. While the toddler will need to be restrained, the parent should not be the one to do this.

2. The nurse should avoid giving the child a choice if there is no choice.

3. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place.

4. The child should be allowed to cry or scream during the procedure.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 16-5: Identify nursing strategies to minimize the stressors related to hospitalization.

17. A child has a planned hospitalization in a few weeks, and the patient and family appear very stressed. What is the best way to minimize the stress for the patient and family?

1. Explain to the patient and family what will be done to the child.

2. Tell the patient and family that the surgeon is very good.

3. Give a tour of the hospital unit or surgical area.

4. Tell the patient and family that everything will be fine.

Correct answer: 3 Rationale: 1. If the patient and family have a full explanation of what will be done to the child, their stress will likely increase instead of decrease.

2. Telling them the surgeon is very good is not going to minimize stress for long. They need to be more familiar with what to expect in a familiar environment.

3. A variety of approaches can be used to provide information and allay fears. Tours of the hospital unit or surgical area are helpful. This activity assists the child and family to become familiar with the environment they will encounter.

4. The nurse cannot know for certain that everything will be fine; thus this should never be offered to the patient or family.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-5: Identify nursing strategies to minimize the stressors related to hospitalization.

18. A family member discusses with the nurse how he would like to be present during any procedures being done to the child. What should the nurse know regarding this request?

1. The child will benefit greatly from family member presence and participation.

2. The child will act out if the parents are present during procedures.

3. The child will be embarrassed for the parents to see her crying.

4. The child would prefer to be alone during the procedure.

Correct answer: 1 Rationale: 1. Parental participation prepares the family for care that will be required when the child goes home. The child benefits greatly from parental presence and participation. The child experiences reduced emotional distress and anxiety if the parents are present.

2. The child is not more likely to act out during procedures when the parent is present.

3. The child will be comforted, not embarrassed, by the parent’s presence during the procedure.

4. Unless the child is old enough to make this request personally, this assumption cannot be made.

Cognitive Level: Synthesis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 16-6: Discuss family presence during procedures and nursing strategies used to prepare the family.

19. When a parent asks to be present during a procedure, the nurse should understand that: 1. The parent wants to ensure that nothing goes wrong with the child.

2. The parent is interested because he is also in the medical field.

3. The parent wants to support his child before, during, and immediately after the procedure.

4. The parent wants to ensure that the correct medication is being used.

Correct answer: 3 Rationale: 1. When a parent asks to be present for a procedure, he is doing so to be available to comfort the child, not to control the procedural outcome.

2. The parent might be in the medical field, but his primary concern is comforting his child during the procedure.

3. Many hospitals now allow parents to be present with their child during and after procedures.

Parents often want to support their child, and their presence offers reassurance and comfort to the child.

4. The parent’s first concern is comforting his child, not supervising the nursing staff.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 16-6: Discuss family presence during procedures and nursing strategies used to prepare the family.

20. The parents have requested to be present during their child’s procedure. How should the nurse plan for this request?

1. Prepare family members for what they should anticipate and what is expected of them.

2. Explain in detail, using medical terms, what will occur.

3. Prepare the family to speak with the physician.

4. Explain to the family that it is not permitted for family member to be present.

Correct answer: 1 Rationale: 1. Parents often want to support their child before and after procedures, and their presence offers reassurance and comfort to the child. Prepare family members for what to anticipate and what is expected of them.

2. The nurse should not use medical terms to discuss the child’s procedure.

3. The nurse can speak to the family to prepare them, and does not need to wait for the physician.

4. In most circumstances, it is not only permitted but desired to have the parents present during a procedure.

Cognitive Level: Analysis Client Need: Psychosocial Integrity

Nursing Process: Planning Learning Outcome 16-6: Discuss family presence during procedures and nursing strategies used to prepare the family.

21. A child is being discharged from the hospital after a three-week stay following a motor vehicle collision. The mother expresses concern about caring for the child’s wounds at home.

She has demonstrated appropriate technique with medication administration and wound care.

The priority nursing diagnosis is: 1. Knowledge Deficient related to home care.

2. Family Processes, Altered related to hospitalization.

3. Parental Anxiety related to care of the child at home.

4. Infection, risk for related to presence of healing wounds.

Correct answer: 3 Rationale: 1. The mother has exhibited correct technique, so this is not the priority diagnosis.

2. The child is being discharged, so this is not the priority diagnosis.

3. While all of the diagnoses might have been appropriate at some point, the current focus is the mother’s anxiety about caring for the child at home. The priority of the nurse is relieving this anxiety.

4. The mother has shown appropriate care of the wounds, decreasing the likelihood of infection, so this diagnosis is not the priority.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Diagnosis

Learning Outcome 16-7: Discuss strategies for preparing children and families for discharge from the hospital setting.

22. A child has been hospitalized for an extended time period, and has been discharged home.

This child requires complex long-term care. What should the nurse teach the family members?

1. How to remove a central line 2. Instruction on oxygen administration 3. Nothing, the family is familiar with the care.

4. How to insert an IV line Correct answer: 2 Rationale: 1. Removing a central line is not within the realm of what family members need to do at home.

2. Prior to discharge, the family might need to learn physical and rehabilitative procedures for the child’s care. For the child requiring complex long-term care, parent might need to learn about oxygen administration.

3. The nurse can never assume the family members are familiar with the care required, even if they have been participating during the hospital stay.

4. Starting an IV line is not within the family’s responsibilities for home care.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 16-7: Discuss strategies for preparing children and families for discharge from the hospital setting.

23. Prior to discharging the child from the hospital, what routine discharge instructions should the nurse discuss with the family?

1. Monitoring of signs and symptoms specific to condition 2. No instructions are needed; the family is familiar with child.

3. Instruction on performing a medical exam on child 4. How to remove all catheters, including central lines Correct answer: 1 Rationale: 1. Families need support and education as they continue to be anxious or stressed over their child’s hospitalization. Standard discharge plans for routine hospital discharge include monitoring signs and symptoms specific to the condition and care at home.

2. The family knows the child, but needs teaching regarding the signs and symptoms to watch for in case of recurrence or complications arise.

3. The family does not need to know how to complete a medical exam on the child.

4. The family should not be given responsibility for removing all catheters and central lines.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 16-7: Discuss strategies for preparing children and families for discharge from the hospital setting.

24. A 2-year-old child recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? The mother: 1. Verbalizes how to give the medication.

2. Acknowledges understanding of written instructions.

3. Draws up the medication correctly in an oral syringe and administers it to the child.

4. Observes the nurse drawing up the medication and administering it to the child.

Correct answer: 3 Rationale: 1. Verbalization of how to give the medication and acknowledging understanding of written instructions are methods that might be used, but they do not actually demonstrate understanding.

2. Verbalization of how to give the medication and acknowledging understanding of written instructions are methods that might be used, but they do not actually demonstrate understanding.

3. The best way for the mother to demonstrate understanding is to actually draw up and give the medication.

4. Observing the nurse drawing up and administering the medication may be used in the teaching process.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment Nursing Process: Evaluation Learning Outcome 16-8: Evaluate the effectiveness of teaching strategies used with the hospitalized child and his family.

25. A nurse is giving instructions to a family whose first language is not English. In order for the teaching to be effective, what type of discussion should the nurse have with the family?

1. Give verbal instruction in English and written instructions in the family’s first language.

2. Ask the family if they would like to have an interpreter present to assist them in understanding the instructions.

3. Give the family instruction booklets written in their first language.

4. Provide the instructions in English and ask the family to repeat the instructions to you.

Correct answer: 2

Rationale: 1. The instructions should be both given verbally and written in the family’s native language.

2. Teaching for parents must be geared to their level of understanding. If English is not spoken, or is the parents’ second language, then a translator might be necessary, and should be offered to the family.

3. The family needs the instructions contained in the booklets, but the nurse also is responsible for ensuring they understand and have no questions. This will require an interpreter.

4. Since English is the family’s second language, this is inappropriate.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 16-8: Evaluate the effectiveness of teaching strategies used with the hospitalized child and his family.

26. The nurse is teaching family members of a child getting ready for discharge how to administer medication via a G-tube for the child. Using the psychomotor domain of teaching, how does the nurse know the teaching was effective?

1. The family is able to give a return demonstration.

2. The family is able to repeat the instructions.

3. The family is able to tell the nurse how they feel about the instruction.

4. The family is able to understand what has been said by the nurse.

Correct answer: 1 Rationale:

1. Depending on the information to be presented, teaching might use the cognitive, psychomotor, or affective domains of learning. If a return demonstration is done, the psychomotor domain of learning is used.

2. The family’s ability to repeat the instructions is within the cognitive domain.

3. The family’s feelings regarding the instruction are within the affective domain.

4. The family’s ability to understand the instructions as said by the nurse is within the cognitive domain.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Evaluation Learning Outcome 16-8: Evaluate the effectiveness of teaching strategies used with the hospitalized child and his family.

1. Which is considered the main relay station for sensory information related to pain?

1. Cerebral cortex 2. Limbic system 3. Thalamus 4. Reticular system Correct answer: 3 Rationale: 1. The cerebral cortex is the second step in processing pain stimuli.

2. The transmission of pain moves through the limbic system after the thalamus.

3. The thalamus is the main relay station for sensory information. Pain information is then transmitted to the cerebral cortex as well as the reticular and limbic system for the processing and interpretation of pain.

4. Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-1: Explain the pathophysiology of pain, as well as the physiology that enables non-painful touch and massage to help reduce pain.

2. When a child is experiencing acute pain, the pain stimulates which system?

1. Adrenergic nervous system 2. Limbic system 3. Autonomic nervous system 4. Reticular system Correct answer: 1 Rationale: 1. Acute pain stimulates the adrenergic nervous system and results in physiology changes, including tachycardia, tachypnea, hypertension, pupil dilation, pallor, increased perspiration, and increased secretion of catecholamine and adrenocorticoid hormones.

2. The limbic system is not stimulated with acute pain.

3. The autonomic nervous system, or the “fight-or-flight” system, is not stimulated with acute pain.

4. The reticular system is not stimulated with acute pain.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-1: Explain the pathophysiology of pain, as well as the physiology that enables non-painful touch and massage to help reduce pain.

3. The nurse is teaching parents about chronic pain. Which statement indicates teaching has been successful?

1. “It is sudden and of short duration.”

2. “It is persistent, lasting longer than six months.”

3. “It is associated with a single event.”

4. “It is associated with pain and discomfort.”

Correct answer: 2 Rationale: 1. Chronic pain is not sudden and short in duration.

2. Chronic pain is persistent, lasting longer than six months; it is often associated with a prolonged disease process, such as juvenile rheumatoid arthritis or cancer.

3. Chronic pain is not associated with a single event.

4. Chronic pain is not associated with pain and discomfort.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 17-1: Explain the pathophysiology of pain, as well as the physiology that enables non-painful touch and massage to help reduce pain.

4. Which behavior will young children most likely display when experiencing acute pain?

1. Thrashing of arms and legs 2. Ability to concentrate

3. Cooperation with treatments 4. Deep sleep Correct answer: 1 Rationale: 1. Young children in acute pain display a variety of behaviors, including loud crying, screaming, thrashing of arms and legs, lack of cooperation, clinging behavior, and restlessness and irritability.

2. It is difficult for children to concentrate when experiencing acute pain.

3. When experiencing acute pain, children are less likely to cooperate with treatments.

4. Children are unable to obtain deep sleep when experiencing acute pain.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-1: Explain the pathophysiology of pain, as well as the physiology that enables non-painful touch and massage to help reduce pain.

5. Which assessment finding(s) is/are most likely to occur in a child with unrelieved postoperative pain?

1. Shallow breaths and suppression of cough 2. Uncontrolled emesis 3. Eating any food being offered after surgery 4. Uncontrolled diarrhea Correct answer: 1 Rationale: 1. Unrelieved pain is stressful, and has many undesirable physiologic consequences. The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain.

2. Children with uncontrolled postoperative pain are more likely to take shallow breaths and avoid coughing than they are to vomit uncontrollably.

3. When children are experiencing unrelieved postoperative pain, they most will likely refuse food after surgery.

4. Unrelieved postoperative pain has little to do with uncontrolled diarrhea.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-2: Describe the physiologic and behavioral consequences of pain in children.

6. The nurse taking care of a postoperative child understands that if the pain is not relieved, there is a potential for: 1. Cardiac complication.

2. Bowel complication.

3. Respiratory complication.

4. Urinary complication.

Correct answer: 3 Rationale: 1. Uncontrolled pain does not lead to cardiac complications.

2. Uncontrolled pain does not frequently lead to bowel complications.

3. The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory complications.

4. Uncontrolled pain does not usually lead to urinary complications.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 17-2: Describe the physiologic and behavioral consequences of pain in children.

7. The nurse understands that the consequences of unrelieved pain can cause an increase in: 1. Stress.

2. Sleep.

3. Healing.

4. Addiction.

Correct answer: 1 Rationale: 1. Unrelieved pain is stressful, and has many undesirable physiologic consequences.

2. Unrelieved pain can make it difficult to obtain restful sleep.

3. Healing is delayed when pain is not adequately relieved.

4. There is no correlation between unrelieved pain and addiction.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 17-2: Describe the physiologic and behavioral consequences of pain in children.

8. The nurse is caring for a 2-year-old child in the postoperative period. The pain assessment tool most appropriate for assessment of pain intensity in a 2-year-old is the: 1. FLACC Behavioral Pain Assessment Scale.

2. Faces Pain Rating Scale.

3. Oucher Scale.

4. Poker Chip Tool.

Correct answer: 1 Rationale: 1. The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain.

2. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

3. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

4. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

Cognitive Level: Application

Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-3: Assess the developmental abilities of children in different age groups to perform a self-assessment of pain intensity, and select an appropriate tool to assess the pain of children in each age group.

9. A 5-year-old is hospitalized with a fractured femur. Which assessment tool is appropriate for this child?

1. Faces Pain Rating Scale 2. SUN Scale 3. PIPP Scale 4. CRIES Scale Correct answer: 1 Rationale: 1. A 5-year-old should be able to use the Faces Scale to choose which face best matches the child’s pain level.

2. The SUN Scale was developed for use in newborns.

3. The PIPP Scale was developed for premature infants.

4. The CRIES Scale was developed for preterm and full-term neonates.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-3: Assess the developmental abilities of children in different age groups to perform a self-assessment of pain intensity, and select an appropriate tool to assess the pain of children in each age group.

10. During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. The nurse should:

1. Administer the prescribed analgesic.

2. Ask the child’s parents if they think the child is hurting.

3. Reassess the child in 15 minutes to see if the pain rating has changed.

4. Do nothing, since the child appears to be resting.

Correct answer: 1 Rationale: 1. School-age children are old enough to report their pain level accurately. A pain score of 6 is an indication for prompt administration of pain medication. The child might be trying to be brave, or might be lying still because movement is painful.

2. The school-age child can answer for herself, and does not need the parents to answer for her.

3. There is no need to reassess, as the child needs pain medication now. 4. The child might be lying quietly because movement increases the pain.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 17-4: Develop a nursing care plan that integrates assessment, pharmacologic 11.

A hospitalized needs to appropriate have an IV restarted.

The child begins tofor cry children when carried interventions, and3-year-old developmentally complementary therapies of different into the treatment room by the mother. The most appropriate nursing diagnosis is: ages with acute pain.

1. Ineffective Individual Coping related to an invasive procedure.

2. Anxiety related to anticipated painful procedure.

3. Fear related to the unfamiliar environment.

4. Knowledge Deficient of the procedure.

Correct answer: 2 Rationale:

1. The child’s behavior is appropriate for coping in this age child.

2. This child is not old enough to understand the need for an IV infusion. The question stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort.

3. The child’s fear is related not to the unfamiliar environment but to the anticipated pain of the IV stick.

4. The question stem indicates that the child has been through this before, so Knowledge Deficient is not the most appropriate diagnosis.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 17-4: Develop a nursing care plan that integrates assessment, pharmacologic interventions, and developmentally appropriate complementary therapies for children of different ages with acute pain.

12. The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. The nurse’s initial action is to: 1. Call the physician to report increasing pain.

2. Administer pain medication.

3. Reposition the child in bed.

4. Check to see if the cast is too tight.

Correct answer: 4 Rationale: 1. The nurse needs to assess the foot prior to calling the physician.

2. The nurse needs to assess the foot prior to administering pain medication.

3. The nurse should not reposition the child until the foot is assessed.

4. The nurse’s initial action is to assess for external factors that might be causing pain.

Cognitive Level: Analysis Client Need: Physiological Integrity

Nursing Process: Assessment Learning Outcome 17-4: Develop a nursing care plan that integrates assessment, pharmacologic interventions, and developmentally appropriate complementary therapies for children of different ages with acute pain.

13. What should the nurse know about opioids when given over an extended period of time?

1. Children can experience withdrawal.

2. The medication will stop relieving the pain.

3. Children will become psychologically dependent.

4. The medication will cause delirium.

Correct answer: 1 Rationale: 1. When given opioids over an extended period of time, children can experience withdrawal, the physical signs and symptoms occurring when a sedative or pain drug is stopped suddenly in a patient with physical dependence.

2. The medication will not stop relieving pain even after an extended period of time.

3. Opioids cause physical, not psychological, dependence when withdrawn.

4. The medication will not cause delirium when taken over an extended period.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning

Learning Outcome 17-5: Contrast the nursing care for children receiving an opioid analgesic and those receiving a non-steroidal anti-inflammatory medication.

14. A nurse is taking care of a patient in the ICU who has been on opioids for an extended period of time. The nurse understands that the child has to slowly wean from the medication over what period of time?

1. Over 2–4 months 2. Over 2–4 hours

3. Over 2–4 weeks 4. Over 2–4 days Correct answer: 3 Rationale: 1. It is not necessary for the child to wean off the opioid over 2–4 months.

2. Weaning over 2–4 hours is too quick, and will cause withdrawal symptoms to occur.

3. Slowly weaning the child off of the opioid over 2–4 weeks will prevent withdrawal symptoms.

4. Weaning over 2–4 days will cause symptoms of withdrawal.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 17-5: Contrast the nursing care for children receiving an opioid analgesic and those receiving a non-steroidal anti-inflammatory medication.

15. An analgesic is ordered for a post-surgical patient to be given every 3–4 hours. The nurse knows that a delay in giving the medication will cause a(n): 1. Increase in the child’s pain tolerance.

2. Decrease in the chance of addiction.

3. Increase in the chance of breakthrough pain.

4. Decrease in the chance of withdrawal symptoms.

Correct answer: 3 Rationale: 1. Delaying the pain medication will not increase the child’s pain tolerance.

2. Delaying the pain medication will not decrease the chance of addiction.

3. Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain.

4. A delay in giving pain medication will not decrease the chance of withdrawal symptoms if the medication is stopped without weaning.

Cognitive Level: Analysis Client Need: Physiological Integrity

Nursing Process: Planning Learning Outcome 17-5: Contrast the nursing care for children receiving an opioid analgesic and those receiving a non-steroidal anti-inflammatory medication.

16. A parent asks the nurse if there is anything that can be done to reduce pain that his 3-year-old experiences each morning when blood is drawn for lab studies. The most appropriate method the nurse can suggest to relieve pain associated with the venipuncture is: 1. Intravenous sedation 15 minutes prior to the procedure.

2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to the skin at least one hour prior to the procedure.

3. Use of guided imagery during the procedure.

4. Use of muscle-relaxation techniques.

Correct answer: 2 Rationale: 1. Sedation is not generally used with quick minor procedures such as venipuncture.

2. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

3. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

4. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 17-6: Compare the effectiveness of pain management strategies for procedures such as venipuncture and immunizations.

17. The nurse is preparing to perform a heel stick on a neonate. The most appropriate complementary therapy for the nurse to plan to use in the neonate to decrease pain during this quick but painful procedure is: 1. Swaddling.

2. Sucrose pacifier.

3. Massage.

4. Holding the infant.

Correct answer: 2 Rationale: 1. Swaddling for a neonate undergoing a quick painful procedure will not decrease the pain.

2. Sucrose provides short-term, natural pain relief, and is most appropriate for use in neonates to decrease pain associated with a quick procedure.

3. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress.

4. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 17-6: Compare the effectiveness of pain management strategies for procedures such as venipuncture and immunizations.

18. A 6-year-old postoperative patient IV has infiltrated, and has to be restarted immediately for medication. There is no time for placing local anaesthetic cream on the skin. What other complementary therapies would be most helpful when placing this IV? 1. Moderate sedation 2. Restraints

3. Distraction 4. Anesthesia Correct answer: 3 Rationale: 1. Moderate sedation has its own side effects and possible complications, and should not be used for quick procedures.

2. Restraints are used only as a last resort, and are not appropriate for an IV start.

3. Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure.

4. Drugs may not be used for quick procedures, such as a dressing change, or an unexpected intravenous insertion, injection, or venipuncture.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 17-6: Compare the effectiveness of pain management strategies for procedures such as venipuncture and immunizations.

19. A nurse taking care of a patient with pain should know that chronic pain is caused by abnormal functioning of the: 1. Autonomic system.

2. Nervous system.

3. Neurological system.

4. Limbic system.

Correct answer: 2 Rationale: 1. The autonomic nervous system is the “fight-or-flight” mechanism, and it is not abnormally affected by chronic pain.

2. Chronic pain can be nociceptic or neuropathic, which is caused by abnormal functioning of the nervous system.

3. The neurological system is not abnormally affected by chronic pain.

4. The limbic system is not abnormally affected by chronic pain.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-7: Contrast the pain management plan for the child with chronic pain and the child with acute pain.

20. A child who has chronic pain of long duration will exhibit which behavior?

1. Increased respiratory rate 2. Normal temperature 3. Decreased blood pressure 4. Normal heart rate Correct answer: 4 Rationale: 1. Chronic pain causes physiologic adaptation, so the respiratory rate likely will be normal.

2. Body temperature is not a factor in chronic pain.

3. As the body adapts to chronic pain, the heart rate will be normal.

4. Chronic pain of long duration that is persistent or continuous permits physiologic adaptation, so normal heart rate, respiratory rate, and blood pressure levels are often seen.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 17-7: Contrast the pain management plan for the child with chronic pain and the child with acute pain.

21. Nurses taking care of children with pain should understand that the pain stimulates the adrenergic nervous system, which will result in which physiologic change?

1. Hypotension 2. Pupil constriction 3. Increased perspiration 4. Bradycardia Correct answer: 3 Rationale: 1. In acute pain, hypertension, not hypotension, occurs.

2. Pupil dilation occurs with acute pain.

3. Acute pain stimulates the adrenergic nervous system and results in physiologic changes, including tachycardia, tachypnea, hypertension, pupil dilation, pallor, increased perspiration, and increased secretion of catecholamine and adrenocorticoid hormones.

4. Bradycardia does not occur with acute pain. The child would experience tachycardia as the adrenergic nervous system was stimulated.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 17-7: Contrast the pain management plan for the child with chronic pain and the child with acute pain.

22. The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia in a pre-op parental meeting, the nurse would explain that patient-controlled analgesia (PCA) is most appropriate for the: 1. Developmentally delayed 16-year-old, postop bone surgery.

2. 5-year-old, postop tonsillectomy.

3. 10-year-old who has a fractured femur and concussion from a bike accident.

4. 12-year-old postop spinal fusion for scoliosis.

Correct answer: 4

Rationale: 1. Children who are developmentally delayed would not be candidates for PCA. 2. PCA generally is prescribed for clients who will be hospitalized for at least 48 hours.

3. Children who have suffered head trauma would not be candidates for PCA. 4. Patient-controlled analgesia is most appropriate in children 5 years old and older. The child must be able to press the button and understand that she will receive pain medicine by pushing the button.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 17-8: Develop a nursing care plan for monitoring the child who receives sedation and analgesia throughout a medical procedure and during recovery.

23. A 5-year-old is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching?

1. “I can expect my child to have some pain for the next few days.”

2. “I will plan to give my child pain medicine around the clock for the next day or so.”

3. “Since my child just had surgery today, I can expect the pain level to be higher tomorrow.”

4. “I will call the office tomorrow if the pain medicine is not relieving the pain.”

Correct answer: 3 Rationale: 1. The child is expected to have some pain for a few days after surgery.

2. The child should receive pain medication on a scheduled basis.

3. Increasing pain can be a sign of complication, and should be reported to the physician; therefore, the nurse should clarify expectations for pain control.

4. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

Cognitive Level: Analysis

Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 17-8: Develop a nursing care plan for monitoring the child who receives sedation and analgesia throughout a medical procedure and during recovery.

24. The nurse is caring for a child who has been sedated for a painful procedure. The priority nursing activity for this child is to: 1. Allow parents to stay with the child.

2. Monitor pulse oximetry.

3. Assess the child’s respiratory effort.

4. Place the child on a cardiac monitor.

Correct answer: 3 Rationale: 1. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

2. Although equipment is important, and is used routinely during sedation, it does not replace the need for visual assessment.

3. When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing.

4. Although equipment is important, and is used routinely during sedation, it does not replace the need for visual assessment.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 17-8: Develop a nursing care plan for monitoring the child who receives sedation and analgesia throughout a medical procedure and during recovery.

1. A concerned parent calls the school nurse because of changes in his 15-year-old’s behavior. In counseling the parents, the nurse would inform them that the behavior that is most likely to be abnormal and indicate possible substance abuse is the adolescent’s: 1. Buying baggy, oversized clothing at thrift shops and dyeing her hair black.

2. Becoming very involved with friends and in activities related to the basketball team that she is on; never seeming to be home; and, when she is home, preferring to be in her room with the door shut.

3. Receiving numerous detentions lately from teachers for sleeping in class.

4. Becoming moody, crying and weeping one minute and then cheerful and excited the next.

Correct answer: 3 Rationale: 1. Experimenting with clothes and hair is a normal adolescent behavior.

2. Periodically distancing themselves from their parents and preferring involvement with their peers are normal adolescent behaviors.

3. Even though most teens do prefer staying up late, they are not usually so tired that they would fall asleep during the day, especially while engaged in classroom activities. This behavior is abnormal, and could indicate involvement with substance abuse or an underlying pathology.

4. Mood swings are normal adolescent behaviors.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 18-1: Identify major social and environmental factors that influence the health of children and adolescents.

2. During a well-child exam, the parents of a 4-year-old child inform the nurse that they are thinking of buying a television for their child’s bedroom, and ask for advice as to whether this is appropriate. The best response from the nurse would be 1. “Research has shown that children with a television in their bedroom spend significantly

less time playing outside than other children.”

2. “Research has shown that watching educational television shows improves a child’s performance in school.”

3. “Don’t buy a television for your child’s room; he is much too young for that.”

4. “It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than two hours per day.”

Correct answer: 1

Rationale: 1. Young children need to be physically active at this age. Research has shown that children with a television in their bedroom spend significantly less time playing outside than do other children, and physical inactivity in children has been linked to many chronic diseases, such as obesity and type 2 diabetes. Telling parents this is the best response because it gives the parents an evidencebased rationale for not placing a television in the child’s room.

2. This statement might encourage increased television watching by the child, and the child’s developmental need for physical activity is greater than the benefit that he might obtain by watching educational programs.

3. “Don’t buy a television for your child’s room; he is much too young for that” does not give parents a rationale, and might seem opinionated to them.

4. “It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than two hours per day” is correct in that limiting television viewing to less than two hours per day is appropriate, but the probability of this occurring with a television in the child’s room is low, and the child will most likely be watching much more than two hours per day.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 18-1: Identify major social and environmental factors that influence the health of children and adolescents.

3. A mother of two children, an 8-year-old and a 10-year-old, tells you that her husband has recently been deployed to the Middle East. The mother is concerned about the children’s constant interest in watching TV news coverage of activities in the Middle East. The most appropriate suggestion for the nurse to make to this mother would be: 1. “Allow the children to watch as much television as they want. This is how they are coping with their father’s absence.”

2. “It will just take some time to adjust to their father’s absence, then everything will return to normal.”

3.

“The less that you discuss this, the quicker the children will adjust to their father’s absence. Try to keep them busy and use distractions to keep their mind off of it.”

4. “Spend time with your children, and take cues from them about how much they want to discuss.”

Correct answer: 4 Rationale: 1. Constant viewing of the TV coverage of the war might increase the children’s anxiety and fear for their father’s safety.

2. The mother should be aware that even though the children might appear to have adjusted, there could be delayed reactions or regressions in behavior.

3. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase.

4. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome 18-1: Identify major social and environmental factors that

influence the health of children and adolescents.

4. A 7-year-old child has been seen in the pediatric clinic three times in the last two months for complaints of abdominal pain. Physical exam and all ordered lab work have been normal. The statement by the nurse working with this child that would be most likely to help determine the etiology of this child’s abdominal pain is: 1. “Have there been any changes in your child’s school or home life recently?”

2. “Tell me what your child usually eats on a normal day.”

3. “Are your child’s immunizations up to date?”

4. “Has your child had any fevers or viral illnesses in the last three months?”

Correct answer: 1 Rationale: 1. With a normal exam and lab work, there is a high probability that this child’s abdominal pain is stress-related, and it is most important to identify the possible stressors in this child’s life to aid in diagnosis and treatment. This question is most likely to get to information about recent stresses in the child’s life.

2. This question is appropriate but will not necessarily obtain information about recent stresses on the child’s life.

3. This question is important related to the overall health status of the child, but does not have anything to do specifically with abdominal pain.

4. With normal blood work and tests, the chances of any illness over the last few months is unlikely. ?”

Cognitive Level: Analysis Client Need: Psychosocial Integrity

Nursing Process: Intervention

Learning Outcome 18-2: List external influences that can affect child and

adolescent health.

5. A recently divorced mother who must return to work is concerned about the effects of placing her child in day care full-time. In counseling the mother, the nurse knows that the factor that is most influential in determining whether day care has a positive or negative effect on the child is: 1. The ratio of child care providers to children.

2. The closeness of the parent–child relationship.

3. The amount of time that the children spend playing outside.

4. The cleanliness of the facility

Correct answer: 2 Rationale: 1. The ratio of child care workers to children can contribute to whether child care is a positive or negative experience, but does not have the greatest impact on the effects of the child care experience.

2. The closeness of the parent–child relationship is more likely to impact how resilient the child is, and this has the greatest impact on the effects of the child care experience.

3. How much time the children are able to spend playing outdoors can contribute to whether child care is a positive or negative experience, but does not have the greatest impact on the effects of the child care experience.

4. The cleanliness of the facility can contribute to whether child care is a positive or negative experience, but does not have the greatest impact on the effects of the child care experience.

Cognitive Level: Analysis Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome 18-2: List external influences that can affect child and adolescent health.

6. The nurse is providing care to homeless teens at an outreach clinic. Which of the following is most important for the nurse to understand?

1. Teens who are homeless are most likely to have unprotected sex.

2. Teens who are homeless will seek help when needed.

3. Teens who are homeless will not be fearful of authority figures.

4. Teens who are homeless will get a job and somewhere to live.

Correct answer: 1 Rationale: 1. Teens who are homeless are more likely to engage in other risky behavior, such as unprotected sex with multiple partners and substance abuse. They are more likely to need emergency care, to be depressed, and to become pregnant, than are other teens.

2. Homeless teens are less likely to seek help when needed, frequently because of mistrust of others.

3. Homeless teens are generally fearful and distrustful of authority figures.

4. Homeless teens are less likely to obtain employment and a place to live, as often these teens do not have the skills to be able to accomplish such tasks.

Cognitive Level: Assessment Client Need: Health Promotion and Maintenance Nursing Process: Analysis Learning Outcome 18-2: List external influences that can affect child and adolescent health.

7. A parent is concerned about her child’s recent behavior, and calls the nurse for advice.

According to the parent, her child is constantly crying, is not sleeping well, and has withdrawn from activities. The nurse should recognize that this behavior is related to: 1. Stress.

2. Drug abuse.

3. Normal behavior.

4. Mental abuse.

Correct answer: 1 Rationale: 1. Children manifest stress in a variety of ways, including regressive behavior, interrupted sleep, hyperactive behavior, gastrointestinal symptoms, crying, and withdrawal from normal events.

2. Drug abuse is more likely to occur in an adolescent, not a child.

3. The beahviors described in the stem are not normal behaviors for a child. Such behaviors need to be investigated.

4. Mental abuse could be a reason for stress, but this answer is limiting when compared to the correct option.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 18-3: Apply the ecologic model and resilience theory to assessment of the social and environmental factors in children’s lives.

8.

At a well-child visit, the parent reports to the nurse that lately, her adolescent is not sleeping

well at night, is very hyperactive, and is complaining of stomach aches. The nurse should be mindful that stressful events can be caused by: 1. Marital difficulties in the family.

2. Overly protective parents.

3. Normal lifestyle.

4. Spoiled adolescents.

Correct answer: 1 Rationale: Common stressful events for children include moving to a new home or school, marital difficulties in the family, abuse, parental deployment in the military, and being expected to achieve at an extremely high level in school or sports.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 18-3: Apply the ecologic model and resilience theory to assessment of the social and environmental factors in children’s lives.

9. The nurse is visiting with a family who just immigrated to the U.S. What should the nurse expect the children to experience?

1. Excitement 2. Culture shock 3. Peer pressure 4. Overly protective parents Correct answer: 2 Rationale: Recent immigrants might experience culture shock, a state of crisis related to the difference in values and lifestyle. This can lead to stress-related symptoms, and create a need for health care intervention Cognitive Level: Analysis

Client Need: Health Promotion and Maintenance Nursing Process: Intervention Learning Outcome 18-3: Apply the ecologic model and resilience theory to assessment of the social and environmental factors in children’s lives.

10. A high school student calls to ask the nurse for advice on how to care for a new navel piercing. The nurse should reply 1. “Apply warm soaks to the area for the first two days to minimize swelling.”

2. “Do not move or turn the jewelry for the first three days.”

3. “Avoid contact with another person’s bodily fluids until the area is well healed.”

4. “Apply lotion to the area, rubbing gently, to prevent skin from becoming dry and irritated.”

Correct answer: 3 Rationale: 1. Ice, not warm soaks, should be applied to the area for the first two days to minimize the swelling.

2. The jewelry needs to be gently rotated several times per day to aid with healing.

3. Until the piercing has healed, it is a non-intact area of skin that has potential for infection, especially from contact with bodily fluids from someone else.

4. Lotion can provide a medium for bacteria, and rubbing at the site can cause irritation to the area.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 18-4: Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

11. The nurse is giving a health promotion class to adolescents. In counseling an adolescent about lifestyle choices, the nurse discusses the fact that the most preventable cause of adult death in the United States is: 1. Alcohol use.

2. Obesity.

3. Tobacco use.

4. Cocaine use.

Correct answer: 3 Rationale: Although all of these factors are preventable causes of mortality in the United States, tobacco use accounts for 430,000 deaths annually, and is the most preventable cause of adult death.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 18-4: Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

12. The school nurse is planning a smoking prevention program for middle school students.

Which is most likely to be effective in preventing middle school children from smoking?

1. Having a local high school basketball star come to talk to the students about the importance of not smoking

2. Having the school’s biology teacher demonstrate the pathophysiology of the effects of smoking tobacco on the body 3. Developing colorful posters with catchy slogans, and placing them all over the school 4. Having a pledge campaign with prizes awarded, during which students sign contracts saying that they will not use tobacco products Correct answer: 1 Rationale:

1. While all of the above strategies are good, the most effective tip would be to have a local high school basketball star come to talk to the students about the importance of not smoking, because students at this age are more likely to listen to and attempt to emulate someone of their own peer group whom they respect and look up to.

2. Information from adults is not likely to influence children of this age more than the pressure of their peers will.

3. Information from posters is not likely to influence children of this age more than the pressure of their peers will.

4. Information from signed contracts is not likely to influence children of this age more than the pressure of their peers will.

Cognitive Level: Analysis

Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 18-4: Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

13. When examining a 2-year-old child during a well-child physical, it is most important for the nurse to assess 1. Visual acuity.

2. Helmet use.

3. Risk of lead exposure.

4. Whether household drinking water contains fluoride.

Correct answer: 3 1. Visual acuity might be difficult to assess accurately at this age secondary to the child’s compliance and ability to understand the directions for the screening test.

2. While teaching helmet use at an early age is important, it is unlikely that this child is riding a bicycle yet.

3. Elevated lead levels are neurotoxic to young children, and can cause irreparable neurological damage if untreated.

4. Although early exposure to fluoride is important for good dental health, lack of fluoridated drinking water will not be as harmful to the child as will toxic lead levels.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 18-5: Evaluate the environment for hazards to children, such as exposure to substances and potential for poisoning.

14. The nurse is seeing a 10-year-old child at a well-child visit. Knowing that risky behavior begins at this age, what is one of the questions she should include in the assessment of this child?

1. Ask if some of the child’s friends have tried smoking.

2. Ask if the child does his homework on time.

3. Ask if he eats a balanced diet every day.

4. Ask if he has friends over regularly.

Correct answer: 1

Rationale: Questions should be inserted into all well-child visits, beginning at about 9–10 years of age.

Inquire whether family members—especially parents and siblings—smoke or chew, and ask if some of the child’s friends have tried smoking.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 18-5: Evaluate the environment for hazards to children, such as exposure to substances and potential for poisoning.

15. What is the role of the nurse in prevention and intervention with youth who smoke?

1. Implement programs for prevention and cessation.

2. Inform parents privately that their children are smokers.

3. Instruct children about the dangers of smoking without their parents present.

4. Give literature about smoking to the children.

Correct answer: 1 Rationale: The roles of nurses in preventing and intervening in youth smoking are to inform youth, identify smokers, and implement programs for prevention and cessation.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 18-5: Evaluate the environment for hazards to children, such as exposure to substances and potential for poisoning.

16. The nurse works in a pediatric unit. In working with a parent who is suspected of Munchausen syndrome by proxy, it is very important for the nurse to: 1. Confront the parent with concerns of possible abuse.

2. Carefully document parent–child interactions.

3. Try to keep the parent separated from the child as much as possible.

4. Explain to the child that the parent is causing the illness, and that the health team will prevent the child from being harmed Correct answer: 2 Rationale: 1. Confronting the parent might alienate the parent and cause her to leave with the child.

2. Munchausen syndrome by proxy is very difficult to prove, and evidence provided by the careful documentation of the nursing staff can be very influential. Care must be taken not to make the parent suspicious, and to keep the child in the hospital until enough evidence is collected.

3. Separating the parent from the child might alienate the parent and cause her to leave with the child.

4. Talking to the child about the health care team’s suspicions could be confusing and frightening for the child.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 18-6: Explore the nursing role in prevention and treatment of child abuse and neglect, and other forms of violence.

17. A child is admitted to the hospital unit with physical injuries. The nurse is taking the child’s history. The statement by the parent that would be most suspicious for abuse is: 1. “I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor.”

2. “The baby’s 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor.”

3. “I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall.”

4. “I was walking up the steps and slipped on the ice, falling while carrying my baby.”

Correct answer: 2 Rationale: 1. This statement is plausible from a developmental prospective.

2. Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib.

3. This statement is plausible from a developmental prospective.

4. This statement is plausible from a developmental prospective.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 18-6: Explore the nursing role in prevention and treatment of child abuse and neglect, and other forms of violence.

18. Which of the following is a likely indicator of abuse of a 2-year-old child?

1. Parents indicating that they did not see the event occur 2. Inconsistency of stories between caregivers

3. Bruising noted on the knees and shins 4. Acting out behavior of the child Correct answer: 2 Rationale: 1. This answer is a logical explanation for this age group.

2. Inconsistency of stories is a red flag for abuse.

3. This answer is a logical explanation for this age group.

4. This answer is a logical explanation for this age group.

Cognitive Level: Implementation Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 18-6: Explore the nursing role in prevention and treatment of child abuse and neglect, and other forms of violence.

19. While the nurse is taking the history of a 10-year-old child, the parents admit to owning firearms. An appropriate safety measure for the nurse to suggest would be which of the following?

1. Using a gun lock on all firearms in the house 2. Taking the child to a shooting range for lessons on how to use a gun properly 3. Storing the guns and ammunition in same places 4. Keeping all the guns in a cabinet Correct answer: 1 Rationale: Statistics show that about 75% of unintentional deaths and suicides are committed with firearms found in the home. The safety measures of using a gun lock, keeping the gun and ammunition separate, and putting the guns in a locked cabinet will at least makes the guns less accessible.

Telling a child that a gun is “dangerous” and not to be touched will probably make it more fascinating. Even with knowledge of the proper use of a firearm, a 10-year-old child’s judgment might not be mature enough to prevent misuse of it.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 18-6: Explore the nursing role in prevention and treatment of child abuse and neglect, and other forms of violence.

20. While working at a weekend “free clinic,” the nurse is assessing a 3-year-old when the mother of the child confides that it has been very difficult providing for her family of four children on her limited budget. She is not sure that she has enough money to buy both food for the rest of the month and the antibiotic that is needed for the child’s ear infection. Which intervention by the nurse would be most beneficial for the child and this family?

1. Giving the mother enough free samples of the antibiotic for the recommended course of treatment 2. Putting the mother in contact with a local agency that provides food on a regular basis to needy families and helps them access other resources in the community 3. Talking with the mother about keeping the child’s ear clean by using a Q-tip

4. Providing the mother with samples of food and food stamps for the child Correct answer: 2 Rationale: While all of these are good interventions, putting the mother in contact with a local agency is most likely to meet the family’s basic need for food and possibly connect the mother to a resource that could supply her with the antibiotic for her child. Also, many uncomplicated ear infections can resolve without antibiotic treatment.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 18-7: Plan nursing interventions for children related to social and environmental situations.

1. A nurse is providing information to a group of new mothers. The nurse would explain that newborns and young infants are more susceptible to infection because they have: 1. High levels of maternal antibodies to diseases to which the mother has been exposed.

2. Passive transplacental immunity from maternal immunoglobulin G. 3. Immune systems that are not fully mature at birth.

4. Been exposed to microorganisms during the birth process.

Correct answer: 3 Rationale: 1. Newborns and young infants do have high levels of maternal antibodies, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection.

2. Newborns and young infants do have passive transplacental immunity, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection.

3. Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection.

4. Newborns and young infants do have exposure to microorganisms during the birth process, but this answer is incorrect because it do not explain the susceptibility of newborns and young infants to infection.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-1: Explain why children are more vulnerable than are adults to infectious and communicable diseases.

2. A nurse is providing education to a group of young mothers. The nurse would explain that as children grow, they develop immunity through: 1. Immunization or exposure to the natural disease.

2. Acquiring diseases from other children.

3. Acquiring diseases from family member who had the disease.

4. Being born with diseases already in their systems.

Correct answer: 1 Rationale: 1. As children grow, they develop immunity through immunization or exposure to the natural disease. As children mature and become more active, they interact more frequently with other children and adults, and also increase their exposure to infectious agents.

2. Acquiring disease from other children would not give children immunity.

3. Children cannot acquire diseases from family members who had the disease 4. Newborns cannot be born with childhood disease.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-1: Explain why children are more vulnerable than are adults to infectious and communicable diseases.

3. The nurse explains to new parents that as healthy children are exposed to more infections, they: 1. Will weaken their immune systems.

2. Naturally develop antibodies.

3. Will acquire terminal illnesses.

4. Are found to be healthier.

Correct answer: 2 Rationale: 1. Exposure to infectious disease will not weaken children’s immune systems.

2. As healthy children are exposed to more infections, they naturally develop antibodies.

3. Exposure to infections, will not lead children to acquire terminal illnesses.

4. Being exposed to infections will not lead to healthy children.

Cognitive Level: Analysis Client Need: Physiological Integrity

Nursing Process: Implementation Learning Outcome 19-1: Explain why children are more vulnerable than are adults to infectious and communicable diseases.

4. The nurse is teaching a child care class for mothers of young children. The nurse tells the parent that the most common mode of transmission of infectious disease is: 1. Children who are playing with the same toy.

2. Children who are coughing.

3. Children who are playing board games.

4. Children who are sitting together eating meals.

Correct answer: 2 Rationale: 1. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases.

2. The fecal–oral and respiratory routes are the most common sources of transmission in children.

3. Playing with board games will not transmit infectious disease.

4. Eating together will not transmit infectious disease.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-2: Describe the process of infection and modes of transmission.

5. The nurse is explaining the importance of handwashing after using the toilet to parents of young children. Which is the most important reason for this practice?

1. Children do not like to have dirty hands.

2. Handwashing is the main way to limit the transmission of disease.

3. Not all bathrooms are clean.

4. Children’s immune systems are not fully developed.

Correct answer: 2

Rationale: 1. This is not a reason for washing hands after using the toilet.

2. The fecal–oral and respiratory routes are the most common sources of transmission in children.

3. Children usually do not wash their hands after toileting unless they are closely supervised.

4. Underdeveloped immune systems will not transmit disease.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-2: Describe the process of infection and modes of transmission.

6. The nurse is teaching parents how to prevent the spread of infectious disease. Which of the following is the most important health promotion strategy for all age groups of children?

1. Keeping child free from colds 2. Keeping all toys clean and free from germs 3. Proper hand hygiene 4. Keeping away from sick adults Correct answer: 3 Rationale: 1. It is not possible to keep children free from colds.

2. Keeping all toys clean and free from germs is not possible.

3. Proper hand hygiene is one of the most important health promotion strategies for all age groups of children as well as child care providers 4. It is not always possible to keep children away from sick adults.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-2: Describe the process of infection and modes of transmission.

7. A child who has not had a tetanus immunization steps on a rusty nail. The child needs immediate protection from tetanus. Which of the following should be given to the child at this time?

1. Antigen 2. Passive immunity 3. Antibodies 4. Active immunity Correct answer: 2 Rationale: 1. Antigen is not given to prevent tetanus.

2. A child who has never had a tetanus immunization needs immediate protection (passive immunity) from tetanus.

3. Antibodies are in the system to fight infections. The child’s immune system will develop antibodies if the child contracts tetanus.

4. If the child contracts tetanus, active immunity will develop in the child’s immune system.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 19-3: Understand the role that vaccines play in reduction and elimination of infectious and communicable diseases.

8. What new vaccine was approved in 2006 to be administered to infants?

1. Rubella 2. Measles 3. Rotovirus 4. Varicella Correct answer: 3 Rationale: 1. Rubella is one of the vaccines on the schedule for infants.

2. The measles vaccine is given to infants as one of the regularly scheduled vaccine.

3. The new rotavirus vaccine was approved for administration to infants in 2006.

4. The varicella vaccine should not be given to infants Cognitive Level: Knowledge Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 19-3: Understand the role that vaccines play in reduction and elimination of infectious and communicable diseases.

9. The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which of the following needles (size and length), injection type, and injection site?

1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh 2. 22-gauge, 1/2-inch needle; IM (intramuscular); dorsogluteal 3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid 4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh Correct answer: 1 Rationale: 1. This vaccine is only given SQ to infants, not IM. 2. A 22-gauge needle is too big for infants, and injections should not be given in the dorsogluteal site.

3. Infants do not receive medication/vaccines in the deltoids 4. The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22–25-gauge, 5/–38/4-inch needle; IM (intramuscularly). The anterolateral thigh is safe to use for this age infant. Research has shown that the ventrogluteal site also may be used safely for this age infant.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 19-4: Develop a nursing care plan for children of all ages needing immunizations.

10. A mother refuses to have her child immunized with the measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. The nurse’s most appropriate response to this mother is to: 1. Honor her request because she is the parent.

2. Explain that antibodies can fight many diseases.

3. Tell her that she is assisting to protect pregnant women against these diseases by not immunizing her infant with the MMR. 4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

Correct answer: 4 Rationale: 1. Honoring her request is not correct, because the nurse has a professional duty to explain that the mother’s belief about immunizations is erroneous, and could result in harm to her infant.

2. Explaining that antibodies can fight many diseases is not correct, because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease.

3. Telling her that not immunizing her infant might protect pregnant women is not correct, because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

4. Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 19-4: Develop a nursing care plan for children of all ages needing immunizations.

11. The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. Provided that a separate injection site is used for all injections, the nurse also may give which of the following immunizations during the same well-child appointment?

1. Varicella 2. Influenza 3. Measles, mumps, and rubella 4. Haemophilus influenza type B Correct answer : 4 Rationale: 1. Varicella (Var) is given at 12–18 months or any time up to 12 years for one dose; for 13 years and older, two doses are given, 4–8 weeks apart.

2. Influenza vaccine may be given yearly to infants after 6 months.

3. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses).

4. Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses).

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 19-4: Develop a nursing care plan for children of all ages needing immunizations.

12. A goal of Healthy People 2010 is full immunization of 95% of children in kindergarten and first grade in the United States. To reach this goal, the school nurse can teach families that: 1. A minor illness with a low-grade fever is a contraindication to receiving an immunization.

2. Vaccines should be given one at a time for optimum active immunity.

3. Premature infants and low-birth-weight infants should receive half-doses of vaccines.

4. The benefits of immunizations outweigh the risks of communicable diseases.

Correct answer: 4 Rationale: 1. A minor illness is not a contraindication to immunization.

2. Giving vaccines one at a time will result in many missed opportunities.

3. Half-doses of vaccines should not be given routinely to premature and low-birth-weight infants.

4. The risks and benefits of vaccines far outweigh the risks from communicable diseases and resulting complications.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 19-4: Develop a nursing care plan for children of all ages needing immunizations.

13. A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the 4-month-old was exposed to a brother who has the flu. In this case, the nurse will: 1. Withhold the vaccinations.

2. Give the vaccinations as scheduled.

3. Withhold the DTaP vaccination but give the others as scheduled.

4. Give the infant the flu vaccination but withhold the others.

Correct answer: 4 Rationale: 1. Recent exposure to an infectious disease is not a reason to defer a vaccine.

2. Giving the vaccine as scheduled will keep the infant properly immunized.

3. There is no reason to withhold any of the vaccinations due at this time.

4. The flu vaccination would not routinely be given to a 4-month-old.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 19-4: Develop a nursing care plan for children of all ages needing immunizations.

14. Which of the following is important to check prior to the administration of a vaccine?

1. Expiration date 2. Lot number 3. Manufacturer’s warranty 4. Date bottle was used Correct answer: 1 Rationale: 1. Always check for expiration date of vaccines and all other medication prior to use.

2. Lot number is recorded by when the immunization is given.

3. Manufacturer’s warranty is not necessary to check prior to giving.

4. Immunizations are supplied in unit dose vials. There is no reason to date the vial when opened.

Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 19-5: Outline a plan to maintain the potency of vaccines.

15. Which of the following should the nurse use when reconstituting vaccines?

1. Sterile water 2. The diluents provided 3. Any solution available 4. Normal saline Correct answer: 2

Rationale: 1. Unless otherwise suggested, use what is suggested by the manufacturer.

2. When reconstituting vaccines, it is important to use the solution provided and follow the manufacturer’s directions.

3. Only use what is suggested by the manufacturer.

4. Not all medications are compatible with normal saline.

Cognitive Level: Comprehension Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 19-5: Outline a plan to maintain the potency of vaccines.

16.

A 3-year-old child is lying in a fetal position. The child has pale skin, glassy eyes, and a flat

affect. The child is irritable, and refuses food and fluids. The child’s vital signs are temperature 40.1°C (104.2°F), pulse 120/minute, respirations 28/minute. The best, most comprehensive description of this child’s condition is: 1. Toxic.

2. Feverish.

3. Flushed.

4. Tired.

Correct answer: 1 Rationale: 1. The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis.

2. The child has a high fever, but this is not the best, most comprehensive description of the child’s condition.

3. The term “flushed” is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.

4. The child might be tired, but this is not the best, most comprehensive description of the child’s condition.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 19-6: Contrast the clinical manifestations of common viral and bacterial infectious and communicable diseases in infants and children.

17. A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. The nurse recognizes that this child might have: 1. Chickenpox (varicella).

2. German measles (rubella).

3. Roseola (exanthem subitum).

4. Fifth disease (erythema infectiosum).

Correct answer: 4 Rationale: 1. Varicella (chickenpox) and rubella (German measles) are unlikely if the child has had all recommended immunizations.

2. The rash of rubella is a pink, maculopapular rash that begins on the face and progresses downward to the trunk and extremities.

3. Roseola typically occurs in infants, and begins abruptly, with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

4. Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign.

Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome 19-6: Contrast the clinical manifestations of common viral and bacterial infectious and communicable diseases in infants and children.

18. The nurse is teaching a class on infectious disease; the nurse understands that zoonosis is only transmitted by: 1. Person to person.

2. Animals to person.

3. Person to insects.

4. Adult to child.

Correct answer: 2 Rationale: Some infectious diseases are transmitted by insects or animals, and are not communicable from person to person.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-6: Contrast the clinical manifestations of common viral and bacterial infectious and communicable diseases in infants and children.

19. A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth for ten days for otitis media. To guard against antibiotic resistance, the nurse instructs the parent to: 1. Administer a loading dose for the first dose.

2. Measure the prescribed dose in a household teaspoon.

3. Give the antibiotic for the full ten days.

4. Stop the antibiotic if the child is afebrile Correct answer: 3 Rationale: 1. A loading dose was not ordered.

2. A household teaspoon could contain less than 5 cc, and the full dose must be given.

3. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria.

4. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-7: Describe the medical and nursing management of common infectious and communicable diseases.

20. The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses are discussing their responsibility in relation to terrorism. The nurse who correctly understood the presentation is the one who identifies their action to be: 1. Separating clients according to age and illness to prevent the spread of disease.

2. Disposing of blood-contaminated needles in the lead-lined container.

3. Notifying the Centers for Disease Control and Prevention (CDC) if a large number of persons with the same life-threatening infection present to the Emergency Department.

4. Initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).

Correct answer: 3 Rationale: 1. Separating clients according to age will do nothing to stop terrorism.

2. Proper disposal of blood-contaminated needles in the sharps container is appropriate nursing actions but does not relate to terrorism.

3. The CDC must be contacted to investigate the source of serious infections and to determine if a terrorist threat exists.

4. Initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) is an appropriate nursing action but does not relate to terrorism.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 19-7: Describe the medical and nursing management of common infectious and communicable diseases.

21. The hospital has instructed its nurses that they must participate in disease surveillance associated with infectious agents. The nurses are warned that which of the following disease(s) are likely to be the weapons of terrorists?

1. Severe acute respiratory syndrome (SARS) 2. Plague, anthrax, and smallpox 3. Rubella, mumps, and chickenpox 4. Rocky Mountain spotted fever and Lyme disease Correct answer: 2 1. SARS is a rare infectious disease.

2. Plague, anthrax, and smallpox are choices of terrorists because they are highly contagious, lethal diseases that can kill large numbers of people in a relatively short time.

3. Rubella, mumps, and chickenpox are childhood communicable diseases that are not usually fatal.

4. Rocky Mountain spotted fever and Lyme disease are caused by ticks endemic to wooded areas.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 19-7: Describe the medical and nursing management of common infectious and communicable diseases.

The 22. hospital admitting nurse is taking a history on a child’s illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media when they report that they:

1. Used aspirin every four hours to reduce the fever.

2. Alternated acetaminophen with ibuprofen every two hours.

3. Put the child in a tub of cold water to reduce the fever.

4. Offered generous amounts of fluids frequently.

Correct answer: 4 Rationale: 1. Aspirin has been associated with Reye’s syndrome, and should not be given to children with a febrile illness.

2. Alternating acetaminophen with ibuprofen every two hours could result in an overdose.

3. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

4. The body’s need for fluids increases during a febrile illness.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 19-7: Describe the medical and nursing management of common infectious and communicable diseases.

23.

The school nurse is trying to prevent the spread of a flu virus through the school. Infection-

control strategies that could be employed include: 1. Teaching parents safe food preparation and storage.

2. Withholding immunizations for children with compromised immune systems.

3. Sanitizing toys, telephones, and doorknobs to kill pathogens.

4. Not separating children with infections from well children.

Correct answer: 3 Rationale: 1. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus.

2. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy.

3. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms.

4. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 19-7: Describe the medical and nursing management of common infectious and communicable diseases.

1. The nurse in the long-term care clinic is reviewing the charts of a group of children with chronic physical, psychological, functional, and/or social limitations. The nurse recognizes that chronic limitations might result from which of the following?

1. Streptococcus pneumoniae, a gram-positive diplococcus 2. Congenital heart defect 3. Pneumonia from haemophilus influenzae virus 4. Type 1 diabetes Correct answer: 2 Rationale: 1. Streptococcus pneumoniae, a gram-positive diplococcus, is treatable, and will not cause chronic limitation.

2. A congenital heart defect can leave a child with a permanent chronic condition.

3. Pneumonia is not a chronic limitation.

4. Type 1 diabetes is not a chronic limitation.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-1: Discuss causes of chronic conditions in children.

2. Which of the following diseases/conditions would most likely leave a child with developmental disabilities?

1. Near drowning 2. Fractured femur 3. Pneumonia from haemophilus influenzae virus 4. Sepsis contracted as a toddler Correct answer: 1 Rationale: 1. Near drowning can leave a child with a permanent chronic condition.

2. A fractured femur is limiting to a child, but will not leave the child with a chronic limitation condition.

3. Pneumonia is treatable, and is not a chronic limitation condition.

4. Sepsis is treatable, and not a chronic limitation condition.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-1: Discuss causes of chronic conditions in children.

3. Which of the following would most likely lead to functional disability of deafness or blindness?

1. Sepsis contracted as a toddler 2. Pneumonia from haemophilus influenzae virus 3. Fetal insult when the mother contracted rubella in the first trimester of pregnancy 4. Fractured femur Correct answer: 3 Rationale: 1. Sepsis is not a chronic condition.

2. Pneumonia is treatable, and is not a chronic condition.

3. Fetal insult when the mother contracted rubella in the first trimester of pregnancy can lead to deafness or blindness.

4. A fractured femur is not a chronic condition.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-1: Discuss causes of chronic conditions in children.

4. The school nurse completes an assessment of a 6-year-old child to determine the services this child will need in the classroom. The child needs respiratory support with oxygen. The child requires enteral tube feedings and intravenous medications during the school day. With these needs, the school nurse evaluates the child to be:

1. Developmentally delayed.

2.

Mentally retarded.

3.

Socially withdrawn.

4.

Medically fragile

Correct answer: 4 Rationale: 1. There is no behavioral evidence to support a finding that the child is developmentally delayed.

2. There is no evidence in the stem that suggests that this child is mentally retarded.

3. The child that is socially withdrawn does not need any special equipment in the classroom.

4. A child who is dependent on medical devices for survival or prevention of further disability is medically fragile. A child who is medically fragile is not necessarily developmentally delayed, mentally retarded, or socially withdrawn.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-2: Describe the categories of chronic conditions in children.

5.

The nurse is conducting an educational session for parents with newborns. Which of the

following information should the nurse would follow up on?

1. “We should have had our newborn tested before birth for high bilirubin.”

2. “We should have our child evaluated if there is difficulty in breathing.”

3. “We should have our child tested if there is a delay in physical development.”

4. “We should have our newborn tested after birth if the baby’s stools are excessive, fatty, and frothy.”

Correct answer: 1 Rationale: 1. High bilirubin is tested after birth. That disorder cannot be detected in utero.

2. A child having difficulty breathing should always be assessed.

3. A child with delayed physical development should be evaluated.

4. Such stools might be a sign of CF, which is evaluated after birth

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome 20-2: Describe the categories of chronic conditions in children.

6. The nurse is partnering with the family of a hospitalized premature infant who suffered an intraventricular brain hemorrhage. The nurse instructs the family that the activities that are appropriate for the infant in the hospital and at home include which of the following? Select all that apply.

1. Interacting face to face 2.

Holding and rocking the infant

3.

Talking softly and singing to the infant

4.

Using a day care for stimulation

5. Discouraging sibling interaction Correct answer: 1, 2, 3 Rationale: 1. Interacting face to face stimulates the infant’s sense of vision, facilitating parent–infant bonding.

2. Holding and rocking the infant stimulates the infant’s sense of motion, facilitating parent– infant bonding.

3. Talking softly and singing to the infant are activities that stimulate the infant’s senses of hearing, touch, and motion, facilitating parent–infant bonding.

4. A premature infant might not have a mature immune system; therefore, day care might present an infection issue. The needs of this child might not be met in a day care setting with many children.

5. Sibling interaction is important, and should be encouraged.

Cognitive Level: Application Client Need: Health Promotion and Maintenance

Nursing Process: Implementation Learning Outcome 20-3: Assess the child with a chronic condition, and identify specific nursing interventions for the child at different ages.

7. At the conclusion of teaching parents about cerebral palsy, the nurse asks, “What is your hope for your toddler with cerebral palsy?” Which of the following replies from a parent best indicates an understanding of a realistic achievement for the child?

1.

“I hope my child qualifies for the Winter Olympics like I did.”

2.

“I hope my child just enjoys life.”

3.

“I hope my child will attend our neighborhood school.”

4.

“I hope my child is liked and accepted by other children.”

Correct answer: 3 Rationale: 1. A child with cerebral palsy does not have the gross motor skills to qualify for the Olympics; thus, this is unrealistic.

2. A hope for the child to enjoy life is realistic, and is not an achievement for the child.

3. Expecting a child with cerebral palsy to do well in the local school is a realistic hope that the child can possibly achieve.

4. A hope that the child is liked and accepted by other children is realistic, and not an achievement for this child.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 20-3: Assess the child with a chronic condition, and identify specific nursing interventions for the child at different ages.

8. The nurse can instruct parents to expect children in which age group to begin to assume more independent responsibility for their own management of a chronic condition, such as blood glucose monitoring, insulin administration, intermittent self-catheterization, and appropriate inhaler use?

1.

Toddlers

2.

Preschoolers

3.

School-age children

4. Adolescents Correct answer: 3 Rationale: 1. Toddlers do not have the cognitive and psychomotor skills for these tasks.

2. Preschoolers do not have the cognitive and psychomotor skills for these tasks.

3. School-age children are developing a sense of industry, and can begin assuming responsibility for self-care.

4. Adolescents should already be well accomplished at self-care.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 20-3: Assess the child with a chronic condition, and identify specific nursing interventions for the child at different ages.

9. The nurse is working in an adolescent medical clinic. When comparing adolescents in the clinic who have chronic conditions with their peers, the nurse would expect chronically ill adolescents to have: 1.

Higher self-esteem.

2.

More concern for their parents.

3.

An altered body image.

4. A decreased concern about their appearance.

Correct answer: 3 Rationale: 1. Adolescents with chronic conditions have low self-esteem when comparing their bodies with those of their peers.

2. As adolescents develop a sense of identity, they are focused on themselves and the present.

3. They might have inaccurate assessments of their body image.

4. They have a heightened concern about their appearance.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 20-3: Assess the child with a chronic condition, and identify specific nursing interventions for the child at different ages.

10. The nurse is working with a group of parents of children with chronic conditions. The nurse concludes that a parent’s caregiver burden could become overwhelming when the parent states which of the following?

1.

“My mother moved in and helps us with the care of our family.”

2.

“Our health insurer sent us a rejection letter for my child’s brand-name medication, and

we must fill out forms to get the generic.”

3.

“I chose to quit my job to be home with my child, and my husband helps in the evening

when he can.”

4.

“I have to care for my child day and night, which leaves little time for me.”

Correct answer: 4 Rationale: 1. The family’s pitching in to help indicates family support.

2. Substituting generic for brand-name medications will not result in caregiver burden.

3. The mother chose to care for the child, and receives help from the husband.

4. No respite time from caregiving responsibilities could lead to overwhelming caregiver burden.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome 20-4: Assess the family of a child with a chronic condition, and discuss the impact of the child’s condition on the family.

11. In working with parents of children with chronic diseases, the nurse is concerned with helping the parents to protect themselves from compassion fatigue. The nurse would encourage which of the following activities? Select all that apply.

1.

Sleeping more than 9 hours per 24-hour period

2.

Exercising

3.

Fostering social relationships

4.

Developing a hobby

5. Moving away Correct answer: 2, 3, 4 Rationale: 1. Sleeping more than the body requires is an avoidance behavior.

2. Exercising contributes to physical restoration.

3. Fostering social relationships contributes to social and mental rest and restoration.

4. Developing a hobby contributes to physical, spiritual, social, and mental rest and restoration.

5. Moving away is an avoidance behavior that does not address exhaustion from overwhelming caregiving responsibilities.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 20-4: Assess the family of a child with a chronic condition, and discuss the impact of the child’s condition on the family.

12. The nurse is working with a child with a chronic condition. The nurse observes that over time, the parents have experienced a pattern of periodic grieving alternating with denial. The nurse would recognize this pattern as: 1.

Chronic sorrow.

2.

Compassion fatigue.

3.

Dysfunctional parenting.

4. Pathological grieving.

Correct answer: 1 Rationale: 1. Parents experience chronic sorrow as they grieve when their child does not meet developmental milestones or participate in activities of “normal” children. The time between periods of grieving might be times of parental denial, which allows the family to function.

2. Compassion fatigue is experienced by caregivers as their ability to feel compassion is exhausted.

3. Dysfunctional parenting involves inadequately meeting the needs of children.

4. Pathological grieving results when persons do not move through the stages of grief to resolution.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 20-4: Assess the family of a child with a chronic condition, and discuss the impact of the child’s condition on the family.

The nurse is conducting a nursing assessment of the parent and child with severe cerebral 13. palsy during a routine clinic visit. Which of the following is important for the nurse to include on this assessment?

1. Observing the parent–child relationship 2. Measuring the child’s head circumference 3. Measuring the urine output 4. Observing how the child interacts during play Correct answer: 1 Rationale: 1. Observing the parent–child relationship is important to the success of health supervision for both the child and parents.

2. Measuring the child’s head circumference is not an important assessment at this time.

3. Measuring urine output is not important unless there are problems with the bladder.

4. Playtime is not important during this time.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-5: Describe family-centered nursing interventions to assist the family of the child with a chronic condition to effectively care for the child in the home.

14. The nurse is conducting an educational program for parents of children with chronic conditions. Which of the following statements should the nurse follow up on?

1. “I know my child will get better and not have to take any more medication.”

2. “I know my child will need assistance with activities of daily living.”

3. “I know my child will have to stay on a special diet.”

4. “I know my child will have to have specialized education.”

Correct answer: 1 Rationale: 1. Chronic conditions might require lifetime dependence on medication.

2. Assistance of daily living activities is needed for children with chronic conditions.

3. Depending on the diagnosis, children with chronic conditions might require a special diet.

4. Children with a chronic condition will require specialized education.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-5: Describe family-centered nursing interventions to assist the family of the child with a chronic condition to effectively care for the child in the home.

15. The nurse is speaking with a parent of a child with cerebral palsy who is also severely developmental delayed. On which of the following should the nurse follow up?

1. “I understand that my child will not be able to play the same as do other children the same age.”

2. “I know my child will not be able to attend the same school as do other children his age.”

3. “I understand that my child will not achieve the same milestones as do other children his age.”

4. “I know my child will be able to perform at the same level as do other children the same age.”

Correct answer: 4 Rationale: 1. Children with severe developmental delays will not achieve the same level as their peers.

2. Although children with chronic conditions who are developmentally delayed can attend school, they will not perform on the same level at will their peers.

3. Children with developmental delays will not achieve the same milestones as the same time as their peers.

4. Chronic conditions can contribute to developmental delays in achieving cognitive and motor milestones.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 20-5: Describe family-centered nursing interventions to assist the family of the child with a chronic condition to effectively care for the child in the home.]

16. The clinic nurse is working with a child with multiple disabilities. The parents have asked the nurse to help them in meeting with the school board in developing an individualized education plan (IEP) and an individualized health plan (IHP). The nurse can best partner with families with a special needs child to develop the child’s IEP by: 1.

Providing a written list of the child’s medical diagnoses for the IEP meeting.

2.

Offering to wait with the child while the parents attend the IEP meeting.

3.

Listening to the parents’ concerns and complaints about the school district.

4. Verbally presenting the child’s cognitive, physical, and social skills to school officials at the IEP meeting.

Correct answer: 4 Rationale: 1. A list of medical diagnoses does not accurately inform school officials about the child’s skills or needs.

2. Waiting with the child might be kind and empathetic, but does not contribute to an action plan for the child’s educational needs.

3. Listening to parents’ concerns might be kind and empathetic, but does not contribute to an action plan for the child’s educational needs.

4. As an advocate for the child and a partner with the family, the nurse attends the IEP meeting and presents the child’s functional skills to develop a comprehensive IEP.

Cognitive Level: Application Client Need: Health Promotion and Integrity Nursing Process: Implementation Learning Outcome 20-6: Describe nursing management for the child with a chronic condition to support transition to school and adult living.

17. The nurse is working with a family of a 5-year-old child with the chronic condition of spina bifida in the lumbar area. The nurse partners with the family to plan goals of care. An appropriate goal for this child and family would be for the parents to: 1.

Refuse a wheelchair for the child to motivate the child to learn to walk.

2.

Verbalize their frustrations to the nurse.

3.

Accept the school district’s individualized transition plan (ITP).

4. Alternately assume care for the child 24 hours a day, seven days a week.

Correct answer: 2 Rationale: 1. A child with spina bifida in the lumbar area requires a wheelchair for mobility.

2. The nurse can assist the parents to talk through their frustrations.

3. The ITP assists adolescents with chronic conditions to transition from school to a vocation and independent living.

4. Parents will suffer caregiver burnout if they have no respite from caregiving and no special time with each other.

Cognitive Level: Application Client Need: Health Promotion and Integrity Nursing Process: Planning Learning Outcome 20-6: Describe nursing management for the child with a chronic condition to support transition to school and adult living.

18. The nurse is teaching family members of an adolescent who is a diabetic and was recently hospitalized for diabetic ketoacidosis (DKA); the family understands that the adolescent, upon returning to school, will: 1. Not necessarily adhere to dietary recommendations.

2. Acknowledge her condition to her classmates.

3. Not experience social stigma.

4. Recognize that there is no difference between her and her classmates.

Correct answer: 1 Rationale: 1. Adolescents have poorer eating habits than all other age groups, adolescents with diabetes may not adhere to necessary dietary restrictions.

2. Adolescents will attempt to hide their health conditions from their classmates.

3. Adolescents might experience social stigma when their classmates find out about a health condition.

4. Adolescents might recognize differences between themselves and others, such as appearance, abilities, and social skills, for the first time.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning

Learning Outcome 20-6: Describe nursing management for the child with a chronic condition to support transition to school and adult living.

19. The nurse is teaching parents and an adolescent who has a chronic condition to transition the adolescent to health care for a young adult. What challenges might the parents and adolescent face?

1. The adolescent and parents might be anxious for this transition.

2. The adolescent and parents are not ready to end the current relationship.

3. Adult health care providers are willing to accept adolescents with chronic conditions.

4. Once the adolescent reaches 21 years of age, he automatically will be insured.

Correct answer: 2 Rationale: 1. Transitioning to an unfamiliar provider might be a challenge for the adolescent, who might not want to leave the comfort of current providers.

2. The adolescent and parents might be unwilling to end a long-term relationship with present health care providers.

3. Adult health care providers might not be available or willing to see young adults with chronic conditions.

4. High rates of insurance or underinsurance exist for adults.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 20-6: Describe nursing management for the child with a chronic condition to support transition to school and adult living.

20. The nurse has set up a group discussion for several families with chronically ill children. The nurse informs these parents that they might face which of the following ethical issues?

1.

Normalization

2.

Withholding and refusal of treatment

3.

Repeated hospital admissions

4. Lack of proper dietary needs Correct answer: 2 Rationale: 1. Normalization is a family process of adaptation as the family copes with daily life with their child.

2. Withholding and refusal of treatment is an ethical issue involving the life and quality of life of the child.

3. Lack of dietary needs is not an ethical issue.

4. Repeated hospital admissions are not an ethical issure.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 20-7: Discuss the family’s role in care coordination and case management.

21. A family actively participates in school functions with all their children, one of whom is paraplegic, and requires a wheelchair for mobility. The nurse evaluates this family to be working on the process of: 1.

Stagnation.

2.

Normalization.

3.

Isolation.

4. Interaction.

Correct answer: 2 Rationale: 1. The family is not staying at home because one member cannot walk.

2. The family is normalizing their life with their children by their activities.

3. The family is moving on to full participation in life.

4. The family is interacting with others through the process of normalization.

Cognitive Level: Application

Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome 20-7: Discuss the family’s role in care coordination and case management.

22. The nurse is discussing the coordination of care with the family. Which of the following indicates the understanding of care coordination?

1. Facilitating communication among multiple professionals is necessary.

2. There is no need to prevent duplication of service.

3. Minimal access to community services needed for the child and family.

4. The child and family’s quality of life will not improve Correct answer: 1 Rationale: 1. Facilitating communication among multiple professional is one of the goals of care coordination.

2. One goal of care coordination is preventing duplication of service, which will result in unnecessary cost.

3. Gaining access to and integrating services and resources on behalf of the child is an important goal.

4. One goal of care coordination is improving the child and family’s quality of life.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 20-7: Discuss the family’s role in care coordination and case management.

1. The nurse is caring for an 8-year-old child who has been in a car accident, has a head injury, and is in the ICU. The nurse sees the child pulling on the IV line. What action should the nurse take?

1. Place soft wrist restraints on the child.

2. Sedate the child as needed.

3. Ask the parents to watch the child closely at all times.

4. Tell the child not to pull on the IV line.

Correct answer: 1 Rationale: 1. Children might interfere with treatment by pulling or removing medical devices; this could necessitate restraints.

2. Due to the head injury, it is not feasible to sedate the child.

3. It is not feasible for the parents to watch the child at all times.

4. The child might not understand what the nurse is trying to convey.

Rationale: 1. Children may interfere with treatment by pulling or removing medical devices; this may necessitate the need for restraints.

2. Due to the head injury it is not feasible to sedate the child.

3. It is not feasible for the parents to watch the child at all times.

4. The child may not understand what the nurse is trying to convey.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 21-1: Discuss the variety of settings in which the nurse might encounter a child with a life-threatening condition.

2. The nurse is taking care of a school-age child with 50% burns to the head and upper part of the body. The nurse recognizes that the most significant stressors for children of this age with lifethreatening illness are: (Select all that apply.)

1. Separation from family.

2. Loss of self-control.

3. Painful and invasive procedures.

4. Fear of the medical team.

5. Disfigurement.

1. Correct answer: 1, 2, 3, 4 Rationale: 1. Young children will have anxiety from separation from family members.

2. Children who are hospitalized fear losing control of self.

3. Fear of painful and invasive procedures will cause stress for children.

4. Children of this age do not usually have fear of the medical team.

5. One stressor for children is fear of disfigurement.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 21-1: Discuss the variety of settings in which the nurse might encounter a child with a life-threatening condition.

3. The nurse is preparing a child for a procedure. Which of the following age groups of children benefits most from being talked to, soothed, and touched during and after the procedure?

1. Toddlers 2. Preschoolers

3. School-age children 4. Adolescents Correct answer: 1 Rationale: 1. Toddlers will benefit from being talked to, soothed, and touched during and after the procedure.

2. Provide preschool children with an explanation of the sensations they can expect to experience.

3. School-age children and adolescents want an explanation of the sensations they can expect.

4. Provide adolescents with an explanation of the sensations they can expect to experience (temperature, vibrations, sounds, smells, tastes, sight).

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 21-1: Discuss the variety of settings in which the nurse might encounter a child with a life-threatening condition.

4. An adolescent with cystic fibrosis is intubated with an endotracheal tube. The most appropriate nursing diagnosis is: 1. Potential for Imbalanced Nutrition, More Than Body Requirements related to inactivity.

2. Anxiety related to leaving chores undone at home.

3. Potential for Fear of Future Pain related to medical procedures.

4.

Powerlessness (Moderate) related to inability to speak to or communicate with friends.

Correct answer: 4

Rationale: 1. The adolescent with cystic fibrosis is likely to be underweight, and is unlikely to take in more calories than needed while intubated.

2. The adolescent is present-, not future-, oriented, and is unlikely to worry about household chores.

3. The adolescent will more affected by powerlessness related to inability to speak, then fear of the unknown. Fear of the unknown is more common in younger children.

4. The adolescent values communication with peers, and might feel frustrated that he cannot speak to them while intubated.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 21-2: Describe the child’s experiences with life-threatening illness according to developmental level.

A 16-year-old boy has a stiff neck, a headache, a fever of 103°Fahrenheit, and purpuric lesions 5. on his legs. He is admitted to the hospital for treatment of suspected meningococcemia. Although the adolescent’s physical needs take priority at the present time, the nurse can expect which of the following to be the most significant psychological stressor for this adolescent?

1. Separation from parents and home 2. Separation from friends and permanent changes in appearance 3. Fear of painful procedures and bodily mutilation 4. Fear of getting behind in schoolwork Correct answer: 2 Rationale:

1. Separation from parents and home is the main psychological stressor for infants and toddlers.

2. Adolescents are concerned about their appearance and how they look compared with their peers. Adolescents are developing their identities, and rely most on their friends.

3. Preschoolers fear pain and bodily mutilation.

4. School-age children are developing a sense of industry and fear getting behind in schoolwork.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 21-2: Describe the child’s experiences with life-threatening illness according to developmental level.

6.

The nurse is caring for a child who has sickle-cell anemia and is in a painful crisis. The most

effective nursing intervention for this child would be: 1. Giving comfort measures, such as back rubs.

2. Suggesting diversional activities, such as coloring.

3. Administering pain medication.

4. Preparing the child for painful procedures.

Correct answer: 3 Rationale: 1. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child, and can be used after pain medication is given.

2. A child in severe pain is not capable of participating in or enjoying diversional activities.

3. Severe pain requires administration of pain medication for pain relief.

4. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 21-2: Describe the child’s experiences with life-threatening illness according to developmental level.

7.

A school bus carrying children in grades K–12 crashed into a ravine. The critically injured

children were transported by ambulance and admitted to the pediatric intensive care unit (PICU).

The nurse is concerned about calming the frightened children. The most effective nursing intervention to achieve this goal is which of the following?

1. Tell the children that the physicians are competent.

2. Assure the children that the nurses are caring.

3. Explain that the PICU equipment is state-of-the-art.

4. Call the children’s parents to come into the PICU. Correct answer: 4 Rationale: 1. Health care providers, no matter how competent or caring, cannot substitute for parents.

2. Children at all developmental levels look first to their parents or whoever acts as their guardians for safety and security.

3. Children often cannot recognize and do not care about state-of-the-art equipment.

4. A sense of physical and psychological security is best achieved by the presence of parents.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 21-2: Describe the child’s experiences with life-threatening illness according to developmental level.

8.

The nurse is taking care of a toddler who is admitted to the hospital for the first time. Which

approach should the nurse take when approaching the child?

1. Make the initial approach with the parent present.

2. Approach the without the parent present.

3. Enter the room hurriedly while talking to the child.

4. Stay outside the room while speaking to the child.

Correct answer: 1 Rationale: 1. Make the initial approach in the parents’ presence whenever possible.

2. Approaching without the parent present will create anxiety in the child.

3. Approach the child slowly when meeting her for the first time.

4. Always enter the room slowly and speak to the parent first and then the child.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 21-2: Describe the child’s experiences with life-threatening illness according to developmental level.

9. A 6-year-old child is in the pediatric intensive care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway, and collided with a car. The nurse can expect which of the following nursing diagnoses for the parents of this child?

1. Guilt related to buying a bicycle for the child 2. Family Coping: Compromised, related to the critical injury of the child 3. Parental Role Conflict related to child’s wellness vs. illness 4. Knowledge Deficit related to home care of fractured femur Correct answer: 2 Rationale: 1. The parent might experience guilt for purchasing a bicycle and not providing a helmet for the child.

2. The parents are displaying ineffective coping behaviors. Parent might be experiencing hopelessness, frustration, and anxiety, and they are not coping well as a family unit.

3. At this point, the parents will not be conflicted or confused whether they want their child well or ill.

4. During the initial phase of the accident, the family is not focusing on discharge planning and care of the fractured femur.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 21-3: Describe the coping mechanisms utilized by the child and family in response to stress.

10. The nurse is taking care of an adolescent who was admitted following an automobile accident. Which of the following should the nurse know in caring for this client?

1. The adolescent’s main concern is with death and dying.

2. Adolescents are concerned with privacy and independence.

3. Adolescents have a fear of loss of self-control related to body.

4. Adolescents will experience separation anxiety.

Correct answer: 2 Rationale: 1. The major source of stress for hospitalized school-age children is concern with death and dying.

2. The adolescent desires privacy and independence.

3. Preschoolers are fearful of loss of self-control related to the body and emotions, and fear of bodily injury or mutilation.

4. Separation from parents is the major stressor for the toddlers.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 21-3: Describe the coping mechanisms utilized by the child and family in response to stress.

11. In caring for a child with a life-threatening illness, the nurse should anticipate the parent’s reaction to the child illness. Which of the following should the nurse anticipate the parent will experience? Select all that apply.

1. Shock and disbelief 2. Anger and guilt

3. Deprivation and loss 4.

Anticipatory

waiting

5.

Readjustment and mourning 1.

Correct answer: 1, 2, 3, 4, 5 Rationale: 1. The universal reaction of parents to a child’s life-threatening illness is shock and disbelief.

2. Anger and guilt surface as parents become more aware of their child’s illness or injury.

3. As the shock associated with the child’s life-threatening condition slowly recedes, new stressors emerge. Parents are deprived of their familiar role of being a parent of a healthy child.

4. Once the child’s condition is stabilized and survival seems likely, parents often move into a period of anticipatory waiting.

5. The last stage that parents experience is readjustment or mourning. Readjustment is experienced as the child recovers.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 21-4: Discuss the family’s experience and reactions to having a child with a life-threatening illness.

12. A child is admitted to the PICU following an accident. The nurse is speaking with the parents regarding preparing siblings to visit. What should the nurse include in the conversation with the parents? Select all that apply.

1. Describe how the sibling looks.

2. Describe in detail what the siblings should expect to see.

3. Describe the hospital environment.

4. Use a doll to show injuries.

5. Discourage the siblings from visiting.

Correct answer: 1, 3, 4

Rationale: 1. Before the visit, talk with the siblings about what to expect, and describe how their sibling will look.

2. Inform siblings about ill siblings using language and concepts appropriate to their ages and developmental tasks.

3. Describe the hospital environment, including equipment, sounds, and smells.

4. Using a doll, drawing pictures, or showing an actual picture of the child can help prepare the siblings.

5. Siblings should be allowed to visit. Such a visit should be encouraged if the child could potentially die.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment

Learning Outcome 21-4: Discuss the family’s experience and reactions to having a child with a life-threatening illness.

13. A 10-year-old child is transported to the Emergency Department by ambulance from the scene of a car accident. He is alert and oriented X 3; his pulse, respirations, and blood pressure are stable; and his neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The child states, “I can’t feel or move my legs.” What injury is most likely?

1. Traumatic brain injury

2. Ruptured spleen 3. Traumatic shock 4. Spinal cord injury

Correct answer: 4 Rationale: 1. Altered levels of consciousness might indicate traumatic brain injury.

2. The child could have a ruptured spleen, but it is not evident from the data given.

3. Traumatic shock results in initially increasing then decreasing pulse and respirations and falling blood pressure.

4. Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and her family.

14. The parents of a 2-year-old child who sustained severe head trauma from falling out of a second-story window are arguing in the pediatric intensive care unit (PICU) and are blaming each other for the child’s accident. The best nursing diagnosis for this family is: 1. Parental Role Conflict related to protecting the child.

2. Hopelessness related to the child’s deteriorating condition.

3. Anxiety related to the critical care unit environment.

4. Family Coping: Compromised, related to the child’s critical injury.

Correct answer: 4 Rationale: 1. Parental Role Conflict does not refer to the parents’ argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role.

2. Each parent might be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

3. Each parent might be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

4. The parents are displaying ineffective coping behaviors as a family.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and the family.

15. The Emergency Department nurse receives a 3-year-old child who was hit by a car. The nurse’s priority intervention is which of the following?

1. Record the parents’ insurance information.

2. Assess airway, breathing, and circulation.

3. Ask the parents about organ donation.

4. Ask the parents if anyone witnessed the accident.

Correct answer: 2 Rationale: 1. Recording insurance information is necessary, but should never come before life-saving

assessment and intervention.

2. Assessing airway, breathing, and circulation is the priority nursing intervention.

3. Asking the parents about organ donation is insensitive until the extent of the child’s injuries is known.

4. Detailed information about the accident is helpful in determining the child’s point of impact with the car and mechanism of injury, but this is not the initial priority.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and the family.

16. The nurse caring for a child who is sedated, unconscious, and on a mechanical ventilator can expect to include which of the following nursing interventions in the nursing care plan?

1. Active range of motion (ROM) exercises 2. Maintenance of intravenous (IV) hydration 3. Out-of-bed transfer to wheelchair 4.

Whirlpool baths

Correct answer: 2 Rationale: 1. The nurse may perform passive ROM exercises on the child, but the child is incapable of doing active ROM exercises.

2. The child who is unconscious is unable to take anything by mouth, and thus will need IV therapy for hydration.

3. The child would not be permitted to be transferred to a wheelchair or take whirlpool baths.

4. The child would not be permitted to be transferred to a wheelchair or take whirlpool baths.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and the family.

17. The nurse is planning a new parent education class for a group of adoptive parents. Which of the following is a priority topic for the class?

1. Chronic diseases in children 2. Congenital birth defects 3. Communicable childhood diseases 4.

Accident prevention

Correct answer: 4 Rationale: 1. Communicable childhood diseases are an appropriate topic, but not a priority over accidents.

2. Pediatric chronic diseases and congenital birth defects are not appropriate topics for a new parent education class.

3. Pediatric chronic diseases and congenital birth defects are not appropriate topics for a new parent education class.

4. Trauma from accidents is the leading cause of death in infants and children; therefore, accident prevention is the priority topic for new parents.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance

Nursing Process: Planning Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and the family.

18. The nurse is working with a 3-year-old child in Bryant’s traction for a fractured femur. A pain assessment scale such as the Oucher Scale can be useful to the nurse caring for this child because use of a pain assessment scale: 1. Provides continuity and consistency in assessing and monitoring the child’s pain.

2. Decreases anxiety in the child.

3. Increases the child’s comfort level.

4.

Reduces the child’s fear of painful procedures.

Correct answer: 1 Rationale: 1. Pain assessment scales are used to assess and monitor pain.

2. Using an assessment scale cannot reduce the child’s anxiety or fear, or increase the child’s comfort level.

3. Using an assessment scale cannot reduce the child’s anxiety or fear, or increase the child’s comfort level.

4. The nurse can reduce anxiety or fear and increase the child’s comfort level by implementing appropriate nursing interventions based on assessment scale data.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and the family.

19. A newborn is admitted to the neonatal intensive care unit (NICU). The parents are concerned because they cannot stay for long hours to visit. Which statement made by the nurse is most appropriate?

1. “One of you might take a leave of absence to be here more.”

2. “Parents often feel this way; you can call any time to see how your baby is doing.”

3. “Perhaps the grandparents can make the visits for you.”

4. “Why can’t you visit after work every day?”

Correct answer: 2 Rationale: 1. This statement does not focus on how the parents feel, and attempts to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

2. This statement is therapeutic; it focuses on feelings and offers support to the parents.

3. This statement does not focus on how the parents feel, and attempts to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

4. This statement does not focus on how the parents feel, and attempts to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

Cognitive Level: Application

Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 21-5: Develop a plan of care for the child with a life-threatening illness and her family. .

1. The nurse working on a pediatric unit is speaking to a child who is terminally ill. The child is describing her illness in terms of mutilation to her body. The nurse understands this to be the development age group of: 1. Infants.

2. Preschoolers.

3. School-age children.

4. Adolescents.

Correct answer: 2 Rationale: 1. Infants and toddlers are not actually aware of death, but they are aware of and react to changes in normal routines and the behavior of parents.

2. Preschool-age children can see their bodies deteriorate and feel the effects of medications used during disease progression and treatment.

3. School-age children have subtle fears about body integrity and anxieties about the seriousness of their illness.

4. Adolescents have a mature understanding of death, but the normal developmental milestones of adolescence add to their problems in facing a terminal illness.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome 22-1: Apply the child’s concept of death and loss to each of these age groups: infants, toddlers, preschoolers, school-age children, and adolescents.

2. The nurse is caring for a child who is terminally ill. The nurse knows the major goals of caring for a dying child are: (Select all that apply.)

1. Promote comfort.

2. Keep the child pain free.

3. Keep the airway free of secretions.

4. Position change.

5. Encourage favorite food.

1. Correct answer: 1, 2, 3, 4, 5 Rationale: 1. A major goal in care of the dying child is to promote comfort.

2. Provide analgesia to promote optimal pain relief. Oral, transdermal, or rectal analgesia is available for families who choose to withhold intravenous fluids.

3. Physiologic care includes keeping the airway clear of secretions.

4. Changing position frequently prevents skin breakdown 5. Offering and encouraging favorite foods and liquids as tolerated should be part of the physical care.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 22-1: Apply the child’s concept of death and loss to each of these age groups: infants, toddlers, preschoolers, school-age children, and adolescents.

3. The nurse is providing postmortem care to a child. Along with following the facility’s guidelines, what else should the nurse consider?

1. The room should remain the same as before death.

2. Identify the family’s wishes for postmortem care before performing care.

3. Remove all articles from patient’s body.

4. Leave all equipment in room during postmortem care.

Correct answer: 2 Rationale: 1. The room should be cleaned according to the guidelines of cultural practices.

2. Identify the family’s wishes for postmortem care before performing any care.

3. Ask before removing any jewelry or other items from the child, because cultural and spiritual practices might specify that the articles remain on the child after death.

4. The nurse can remove the equipment in the room during postmortem care.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 22-2: Identify the cultural and spiritual influences on the child and family’s responses to death, loss, and grief.

4. Nurses are caring for children with life-threatening illness. Which of the following religious groups should the nurse know forbids organ donation, and therefore should not contact regarding organ and tissue donation?

1. Hinduism 2. Buddhism 3. Islam 4. Jehovah’s Witness Correct answer: 4 Rationale: 1. In Hinduism, autopsy and organ donation are acceptable.

2. In Buddhism, organ donation is considered an act of mercy.

3. In Islam, organ donation is acceptable.

4. Jehovah’s Witnesses forbid organ donation.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 22-2: Identify the cultural and spiritual influences on the child and family’s responses to death, loss, and grief.

5. The nurse is caring for a child who is dying. The parent asks that the child not be told he is dying. The child asks you if he is dying. Which of the following would be the most appropriate action by the nurse at this time?

1. Tell the child he is dying and offer to stay with him.

2. Offer to bring in the child life therapist.

3. Ignore the child’s question and change the subject.

4. Suggest a meeting with the health care team to the parents.

Correct answer: 4 Rationale: 1. This is going against the parents’ wishes.

2. Avoiding the subject is not an option.

3. Changing the subject or ignoring the child is not good.

4. Offering to set up a meeting with the health care team to discuss the parents’ fears and concerns about telling their child the truth is the best action by the nurse.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 22-3: Intervene with the child’s responses to impending death.

6. The nurse is caring for a dying child. The nurse understands that the major goal for a child who is dying is to: 1. Promote comfort and keep the child pain-free.

2. Ensure that a good relationship is maintained with the family.

3. Keep the child entertained so she does not think about dying.

4. Maintain a busy schedule for child and family members.

Correct answer: 1 Rationale: 1. The major goal for the dying child is to promote comfort and keep the child pain-free.

Provide analgesia to promote opitmal pain relief.

2. Maintaining a good relationship is important but not a major goal for the child’s care.

3. Keeping the child entertained is good, but he needs to voice his feelings about death and dying.

4. A dying child does not have the energy to maintain a busy schedule.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 22-3: Intervene with the child’s responses to his impending death.

7. The nurse is caring for a child who is dying. The nurse is feeling conflicted when the parents are unable to discontinue aggressive therapy that the nurse feels is extending the child’s suffering. Which action by the nurse is most appropriate?

1 Call a meeting with the physician taking care of the patient. .

Talk to the parents and convince them this is not right.

2 Inform the nurse manager that she needs to talk with the parents. .

3 .

4 .

Consult with the hospital Ethics Committee.

Correct answer: 4 Rationale: 1. Calling a meeting with the physician taking care of the child will not resolve the conflict the nurse is having.

2. Being judgmental and trying to convince the parents might be considered a conflict of interest.

3. The nurse manager can speak with the parents, but she is not in a position to convince the parents that what they are doing is not right.

4. Consultation with a member of the hospital Ethics Committee can help clarify the issues involved and reduce the emotions associated with the conflict.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 22-4: Describe ethical issues associated with the care of a child who is dying.

8. The nurse is taking care of a child who is dying. The child has a DNR order. Which of the following care and interventions should the child with a DNR order receive? Select all that apply.

1. Oxygen 2. Suctioning 3. Pain control 4. Tube feeding 5. Physical therapy 1. Correct answer: 1, 2, 3 Rationale: 1. The family should understand that the child will receive further care and interventions such as oxygen, suctioning, pain control, and supportive nursing care in the presence of a DNR order.

2. The family should understand that the child will receive further care and interventions such as oxygen, suctioning, pain control, and supportive nursing care in the presence of a DNR order.

3. The family should understand that the child will receive further care and interventions such as oxygen, suctioning, pain control, and supportive nursing care in the presence of a DNR order.

4. Tube feeding is not considered when a DNR is in place, because it continues to sustain life.

5. Physical therapy is inappropriate at this time.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 22-4: Describe ethical issues associated with the care of a child who is dying.

9. The nurse is taking care of a child who is showing signs of imminent death. What changes should the nurse expect to see with the cardiovascular system?

1. Peripheral circulation increases.

2. A increase in the volume of Korotkoff’s sounds 3. The heart rate might initially increase as hypoxia develops.

4. Increase in cardiac output Correct answer: 3 Rationale: 1. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skink; and changes in skin coloring.

2. A change in pulse pressure and a decrease in the volume of Korotkoff’s sounds indicate imminent death.

3. The heart rate might initially increase as hypoxia develops, then the heart rate and blood pressure decrease, resulting in decreased cardiac output.

4. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 22-5: Apply assessment skills to identify the physiologic changes that occur in the dying child.

10. The nurse is taking care of a child who is showing signs of imminent death. What changes should the nurse expect to see with the respiratory system?

1. Periods of shallow breathing alternating with apnea 2. Dyspnea and increased breath sounds 3. Muscles tightening with secretion accumulation in the bronchi 4. Normal cardiac function Correct answer: 1 Rationale: 1. Cheyne-Stokes respiration (periods of shallow breathing alternating with apnea) is a sign of imminent death.

2. Impaired cardiac function leads to pulmonary congestion, tachypnea, diminished breath sounds, and hypoxia.

3. As the muscles relax, secretions accumulate in the oropharynx and bronchi. The “death rattle” is caused by air passing through these secretions.

4. Impaired cardiac function leads to pulmonary congestion, tachypnea, diminished breath sounds, and hypoxia.

Cognitive Level: Analysis

Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 22-5: Apply assessment skills to identify the physiologic changes that occur in the dying child.

11. The nurse is taking care of a child who is showing signs of imminent death. What changes should the nurse expect to see with the neurological system?

1. Decreased cerebral perfusion, hypoxemia, and metabolic acidosis 2. Hearing and vision becomes more heightened.

3. Remains calm, heightened alertness.

4. Alert to current time and place Correct answer: 1 Rationale: 1. Decreased cerebral perfusion, hypoxemia, metabolic acidosis, the influences of diseaserelated factors, and an accumulation of toxins from renal and liver failure lead to neurological dysfunction.

2. Hearing and vision acuity might deteriorate, but remember that hearing is thought to be the last of the senses to diminish before death.

3. Agitation or restlessness, withdrawal, increasing drowsiness, and confusion can occur; the child might be unconscious during her final hours.

4. The child might speak of vision (persons or objects) not visible to others.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment

Learning Outcome 22-5: Apply assessment skills to identify the physiologic changes that occur in the dying child.

12. A 12-year-old child with congenital heart block codes in the Emergency Department. The parents witness this and stare at the resuscitation scene unfolding before them. The best nursing intervention in this situation is to: 1. Ask the parents to leave until the child has stabilized.

2. Ask the parents to call the family to come in to watch the resuscitation.

3. Ask the parents to sit near the child’s face and hold his hand.

4. Ask the parents to stand at the foot of the cart to watch.

Correct answer: 3 Rationale: 1. Parents should never be asked to take part in emergency efforts unless absolutely necessary.

2. Having family merely watching the resuscitation serves no purpose for the child.

3. Parents should be helped to support their child through emergency procedures, if they are able.

4. If the parents interfere with resuscitation efforts, or they are unable to tolerate the situation, they can be asked to leave later.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 22-6: Develop a nursing care plan to provide family-centered care for the dying child and his family.

13. The nurse is taking care of a child with a life-threatening condition. The child’s condition is stabilized, and survival seems likely. What reaction would the nurse expect to witness from the parents?

1. Shock and disbelief 2. Anger and guilt 3. Depression and loss 4. Anticipatory waiting Correct answer: 4 Rationale: 1. The universal initial reaction of parents to a child’s life-threatening illness is shock and disbelief.

2. Anger and guilt surface as parents become more aware of their child’s illness or injury.

3. As the shock associated with the child’s life-threatening condition slowly recedes, new stressors emerge.

4. Once the child’s condition is stabilized, and survival seems likely, parents often move into a period of anticipatory waiting.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 22-6: Develop a nursing care plan to provide family-centered care for the dying child and his family.

14. An adolescent with a gunshot wound presents to the Emergency Department with his distraught parents. He states that he saw his teacher and several classmates shot by a fellow

classmate. As a result of the shooting incident, the nurse expects this adolescent to be at risk for: 1. Post-traumatic stress disorder.

2. School phobia.

3. Depression.

4. Conduct disorder Correct answer: 1 Rationale: 1. Acute stress, parental stress, and the degree of the psychological trauma exposure are variables predictive of post-traumatic stress disorder (PTSD).

2. School phobia could possibly occur later.

3. Depression could possibly occur later.

4. Conduct disorder could possibly occur later.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 22-7: Implement strategies for bereavement support of the parents and siblings after the death of a child.

15. The nurse is counseling some parents on how they will feel after the death of a child. The nurse understands that the parents might feel which of the following? Select all that apply.

1. Anger 2. Guilt 3. Depression

4. Loneliness 5. High energy Correct answer: 1, 2, 3, 4 Rationale: 1. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

2. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

3. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

4. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

5. High energy is not felt during the mourning period.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 22-7: Implement strategies for bereavement support of the parents and siblings after the death of a child.

16. The nurse is speaking with a preschool-age child whose sibling recently died. The nurse understands that preschool-age siblings might feel that the death was due to: 1. The child’s having thoughts about their sibling dying.

2. The child’s being bad, and the sibling being punished.

3. The child’s having a fight with their sibling.

4. Their parents’ not liking that sibling.

Correct answer: 1 Rationale: 1. Preschool-age children might fear that they caused their brother or sister to be injured or become ill, or worry that bad thoughts on their part brought on the illness.

2. Preschool-age children do not have a fear of being bad and the sibling’s subsequently being punished.

3. Fighting is normal, and preschool-age children do not have those thoughts.

4. Preschool-age children are more likely to believe that they somehow was the cause of their sibling’s death, not their parents’ fault.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 22-7: Implement strategies for bereavement support of the parents and siblings after the death of a child.

17. The nurse is having difficulty coping with the impending death of a child. Which of the following would most likely be the best resource for the nurse at this time?

1. Unit manager 2. Co-workers 3. Spouse 4. Hospice nurses Correct answer: 4 Rationale: 1. The unit manager also might have a difficult time with the impending death.

2. Co-workers will also have a difficult time with the death.

3. The spouse might not fully understand why this is affecting the nurse.

4. Mentorship with experienced hospice nurses as well as additional educational experiences could help promote professional nursing care.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 22-8: Describe strategies to support nurses who care for children who die.

18. The nurse must prepare parents to see their adolescent daughter in the pediatric intensive care unit (PICU). The child arrived by life flight after experiencing multiple traumas in a car accident involving a suspected drunk driver. At this time, the priority nursing statement would be which of the following?

1. “Don’t worry; everything will be okay. We will take excellent care of your child.”

2. “You should press charges against the drunk driver.”

3. “Your child’s leg was crushed, and might have to be amputated.”

4. “Your child’s condition is very critical; her face is swollen, and she might not look like herself.”

Correct answer: 4 Rationale:

1. The nurse must not offer false reassurance or project future stressful events.

2. The nurse supports the family but remains nonjudgmental about accident details.

3. Truthful statements about the child’s condition can be introduced after the parents have

seen the child and grasped the situation.

4. The priority is to prepare the parents for the child’s changed appearance.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 22-8: Describe strategies to support nurses who care for children who die.

1. Fluid moves between the intravascular and interstitial compartments by a process called: 1. Osmosis.

2. Filtration.

3. Buffer.

4. Alkalosis.

Correct answer: 2 Rationale: 1. Osmosis is when water moves into and out of the cells.

2. Fluid moves between the intravascular and interstitial compartments by a process called filtration.

3. A buffer is a compound that binds hydrogen ions when their concentration rises and releases them when their concentration falls.

4. Alkalosis is a decrease in pCO2.

Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 23-1: Describe normal fluid and electrolyte status for children at various ages.

2. Which of the following loses the greatest proportion of fluid each day?

1. Adolescent 2. Newborn 3. Infant 4. Adult Correct answer: 3 Rationale:

1. Adolescents have a smaller body surface area, and therefore have a lesser insensible water loss through the skin.

2. Newborn brain and skin occupy a greater proportion of body weight, and are high in interstitial fluid.

3. Infants have a high body surface area, which promotes fluid loss.

4. Adults’ kidneys are mature, and therefore able to conserve water and electrolytes and fully assist in acid–base balance.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 23-1 Describe normal fluid and electrolyte status for children at various ages.

3. The condition where serum sodium is below normal levels, resulting in fluid loss characterized by a proportionately greater loss of sodium than water, is: 1. Isotonic dehydration.

2. Hypotonic dehydration.

3. Hydrostatic pressure.

4. Osmotic pressure.

Correct answer: 2 Rationale: 1. This occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion.

2. This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water. Serum sodium is below normal levels.

3. This occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins.

4. This occurs when much of the osmotic pressure that pulls fluid into the capillaries is due to the presence of albumin and other plasma proteins made by the liver.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome 23-2: Identify regulatory mechanisms for fluid and electrolyte balance.

4. A nurse is taking care of four different pediatric clients. Which of the following children is at greatest risk for dehydration?

1. 7-year-old child with migraine headaches 2. 18-month-old child with tachypnea 3. 4-year-old child with a broken arm 4. 2-year-old child with cellulitis of the left leg Correct answer: 2 Rationale: 1. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system is at a lower risk than is a toddler with a condition that increases insensible water loss.

2. The pediatric client with the greatest risk is under 2 years of age and with a condition that increases insensible fluid loss.

3. The pediatric client with an acute condition that does not directly affect electrolytes is at a lower risk than is a client with a condition that increases insensible water loss.

4. The pediatric client with an acute condition, such as a patient with cellulitis that does not affect the GI or electrolyte system, is at a lower risk than is a toddler with a condition that increases insensible water loss.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 23-3: Recognize threats to fluid and electrolyte balance in children.

5. The nurse has just finished a parent teaching session on preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught?

1. Hydration should occur at the end of an exercise session.

2. Water is the drink of choice to replenish fluids.

3. Wearing dark clothing during exercise is recommended.

4. During activity, stop for fluids every 15–20 minutes.

Correct answer: 4 Rationale: 1. Hydration should occur before and during the activity, not just at the end.

2. A combination of water and sports drinks is best to replace fluids during exercise.

3. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating 4. During activity, stopping for fluids every 15–20 minutes is recommended.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation

Learning Outcome 23-3: Recognize threats to fluid and electrolyte balance in children.

The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert 6. but has dry mucous membranes. Which other sign indicates the infant is still in the early or mild stage of dehydration?

1. Tachycardia 2. Bradycardia 3. Increased blood pressure 4. Decreased blood pressure Correct answer: 1 Rationale: 1. Tachycardia is a sign that indicates mild dehydration.

2. Bradycardia is not a sign of dehydration.

3. Increased blood pressure is not a sign of dehydration.

4. Decreased blood pressure is not a sign of mild dehydration.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

7. A 1-month-old infant is admitted to the Emergency Department with severe diarrhea. Which of the following assessments suggests the infant is severely dehydrated?

1. Skin moist and flushed; mucous membranes dry 2. Low specific gravity of urine; skin color pale 3. Fontanels depressed; capillary refill greater than three seconds 4.

High specific gravity of urine; moist mucous membranes

Correct answer: 3 Rationale: 1. Moist, flushed skin and moist mucous membranes are not signs of dehydration.

2. Low specific gravity of urine is not a sign of dehydration.

3. Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds.

4. Moist mucous membranes are signs of dehydration. High specific gravity of urine is not a severe sign of severe dehydration.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

8. In the morning, a nurse receives a report on four pediatric clients each of whom have some form of fluid-volume excess. Which of the following children should the nurse see first? The one with: 1. Periorbital edema and normal respiratory rate.

2. Tachypnea and pulmonary congestion.

3. Dependent and sacral edema, and regular pulse.

4. Hepatomegaly and normal respiratory rate.

Correct answer: 2 Rationale: 1. The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

2. A child with respiratory distress should be the first client the nurse checks after receiving report.

3. The child with dependent and sacral edema and regular pulse is more stable than the child with tachypnea and pulmonary congestion.

4. The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

9. The nurse is caring for a child on bedrest who has severe edema in a left lower leg due to blocked lymphatic drainage. A priority nursing diagnosis would be: 1. Risk for Imbalanced Nutrition: Less Than Body Requirements.

2. Risk for Impaired Skin Integrity.

3. Risk for Altered Body Image.

4.

Risk for Activity Intolerance.

Correct answer: 2

Rationale: 1. Nutrition would not take priority over the integrity of the skin for this scenario.

2. The highest-priority problem is skin integrity.

3. Body image would not take priority over the integrity of the skin for this scenario.

4. Activity intolerance would not take priority over the integrity of the skin for this scenario.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

10. A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to an LVN, cautions the LVN that the child should be watched for: 1. Seizures.

2. Bradycardia.

3. Respiratory distress.

4. Hyperthermia.

Correct answer: 1 Rationale: 1. A child with hyponatremia is at risk for seizures.

2. Bradycardia is not a risk of hyponatremia.

3. Respiratory distress is not a risk of hyponatremia.

4. Hyperthermia is not a risk of hyponatremia.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

11. A nurse is planning care for a child with hyperkalemia. The nurse explains to the parents that an adverse outcome of hyperkalemia is: 1. Seizures.

2. Cardiac arrhythmias 3. Respiratory distress.

4.

Hyperthermia.

Correct answer: 2 Rationale: 1. Seizures are not a risk of hyperkalemia.

2. A child with hyperkalemia is at risk for cardiac problems such as arrhythmias that can be lifethreatening.

3. Respiratory distress is not a risk of hyperkalemia.

4. Hyperthermia is not a risk of hyperkalemia.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

12. A child with croup has an increased pCO2, a decreased pH, and a normal HCO3 blood gas value. The nurse interprets this as uncompensated: 1. Respiratory acidosis.

2. Respiratory alkalosis.

3. Metabolic acidosis.

4.

Metabolic alkalosis.

Correct answer: 1 Rationale: 1. If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis.

2. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2, and normal HCO3; 3. Uncompensated metabolic acidosis has a decreased pH, normal pCO2, and normal HCO3.

4. Uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 23-4: Analyze assessment findings to recognize fluid–electrolyte problems and acid–base imbalance in children.

13. The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the doctor to order initially to replace fluids?

1. D5W 2. 0.9% normal saline (NS) 3. Albumin 4. D5 0.2% (¼) normal saline Correct answer: 2 Rationale: 1. D5W can lower sodium levels, and so would not be used to initially replace fluids in severe isotonic dehydration.

2. 0.9% normal saline (NS) is an isotonic fluid, and maintains Na and chloride at present levels.

3. Albumin is used to restore plasma proteins.

4. D5 0.2% (¼) normal saline would not be used initially but later, as maintenance fluids.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 23-5: Describe appropriate interventions for children experiencing fluid– electrolyte problems and acid–base imbalance.

14. Parents of an infant with slow weight gain ask the nurse if they can feed their baby a highly concentrated formula. An appropriate response given by the nurse would be: 1. “A higher-concentrated formula could lead to dehydration because of high sodium content;

let’s discuss other strategies.”

2. “An undiluted formula concentrate could be given to help the child gain weight; let’s look at brands.”

3. “Evaporated milk could be given to the infant instead of the current formula you’re using.”

4.

“A higher-concentrated formula could be given for daytime feedings; let’s work on a

schedule.”

Correct answer: 1 Rationale: Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula, concentrate, or evaporated milk, due to the high sodium content.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 23-5: Describe appropriate interventions for children experiencing fluid– electrolyte problems and acid–base imbalance.

15. A 6-year-old child is hypokalemic. The nurse is helping the child complete the menu. The nurse would encourage this child to select: 1. A hamburger with French fries.

2. Pizza with a fruit plate.

3. Chicken strips with chips.

4. Fajita with rice.

Correct answer: 2 Rationale: 1. A hamburger and French fries do not have any potassium.

2. Pizza with a fruit plate should be encouraged because fruit (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.

3. Chicken strips and chips do not have any potassium.

4. Fajitas and rice do not have any potassium.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Intervention Learning Outcome 23-5: Describe appropriate interventions for children experiencing fluid– electrolyte problems and acid–base imbalance.

16. A child is admitted to the hospital for hypercalcemia, and is placed on diuretic therapy.

Which diuretic would the nurse expect to give?

1. Hydrochlorothiazide (Aquazide) 2. Spironolactone (Aldactone) 3. Furosemide (Lasix) 4. Mannitol (Osmitrol) Correct answer: 3 Rationale: 1. Thiazide diuretics (like hydrochlorothiazide) decrease calcium excretion, and should not be given to the hypercalcemic client.

2. Spironolactone (Aldactone) is a potassium-sparing diuretic, and would not be effective for excretion of calcium.

3. Furosemide (Lasix) is the diuretic used to aid in excretion of calcium.

4. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema, and is not routinely used to aid in excretion of calcium.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 23-5: Describe appropriate interventions for children experiencing fluid– electrolyte problems and acid–base imbalance.

Commented [WP1]: Looks like repeat of question 16

17. The nurse is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: Intake: 4 ounces of Pedialyte One-half of an 8-ounce cup of clear orange Jell-O Two graham crackers 200 cc of D 5 1/2 sodium chloride IV Output: 345 cc of urine 50 cc of loose stool How many milliliters should the nurse document as the client’s intake?

1. 440 2. 345 3. 200 4. 220

Correct answer: 1 Rationale: Pedialyte, Jell-O, and IV fluid would be calculated for intake. The child has had 240 cc orally and 200 cc intravenously for a total of 440.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 23-5: Describe appropriate interventions for children experiencing fluid– electrolyte problems and acid–base imbalance.

18. A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg, and is estimated to have lost 7% of his normal body weight. The nurse is double-checking the IV rate the physician has ordered. The formula the physician used was for maintenance fluids: 1,000 mL for 10 kg of body weight plus 50 cc for every kg over 10 for 24 hours.

Replacement fluid is the percentage of lost bodyweight  10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, this child’s hourly IV rate for 24 hours should be: 1. 88.

2. 86.

3. 83.

4. 81.

Correct answer: 2 Rationale: Maintenance need for 13 kg is 1,000 + (50 [] 3), or 1,150 mL/24 hours. Add to this the replacement fluid loss = 7 (% of total body weight lost)  10 = 70 mL/kg/24 hours (70  13 = 910). 1,150 + 910 = 2,060 for 24 hours. 2,060/24 = 86 cc per hour.

Cognitive Level: Application

Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 23-5: Describe appropriate interventions for children experiencing fluid– electrolyte problems and acid–base imbalance.

1. The nurse is caring for a young child with otitis media. The parent asks the nurse what causes otitis media. Which of the following is the best response by the nurse?

1. The eustachian tube is shorter, wider, and horizontal in younger children.

2. The eustachian tube is longer, more narrow, and vertical in younger children.

3. The eustachian tube is shorter, more narrow, and horizontal in younger children.

4. The eustachian tube is longer, wider, and vertical in younger children.

Correct answer: 1 Rationale: The eustachian tube, which connects the nasopharynx to the middle ear, is proportionately shorter, wider, and more horizontal in infants than in older children or adults. This promotes an increase in the incidence of ear infections.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 24-1 Identify anatomy and physiology, as well as pediatric differences, in the eye, ear, nose, and throat of children and adolescents.

The nurse is teaching young parents on the proper techniques for feeding young children 2. who are bottle-fed. The nurse should instruct the parents to feed the children in an upright position in order to prevent: 1. Sinus infection.

2. Choking.

3. Aspiration.

4. Otitis media.

Correct answer: 4 Rationale:

1. Young children are not prone to sinus infection at that age.

2. Choking results from holes in bottle nipples that are too big.

3. Aspiration is caused by feeding too much too fast.

4. Small children who are bottle-fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks, and the horizontal angle provides easy access in the middle ear.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 24-1: Identify anatomy and physiology, as well as pediatric differences, in the eye, ear, nose, and throat of children and adolescents.

3. The nurse is caring for four clients. The client with the greatest risk of developing retinopathy of prematurity is the: 1. 30-weeks’-gestation infant who was in an oxyhood for 12 hours and weighed 1,800 grams.

2. 32-weeks’-gestation infant who needed no oxygen and weighed 1,850 grams.

3. 28-weeks’-gestation infant who has been on long-term oxygen and weighed 1,400 grams.

4. 28-weeks’-gestation infant who was on short-term oxygen and weighed 1,420 grams.

Correct answer: 3 Rationale: 1. The 30-weeks’-gestation infant was on oxygen for short period of time.

2. The 32-weeks’-gestation infant was not placed on oxygen, and therefore is not at risk.

3. The 28-weeks’-gestation infant on oxygen weighing 1,400 grams has the greatest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less

than 1,500 g), and oxygen therapy.

4. The 28-weeks’-gestation infant was only placed on short-term oxygen.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome 24-2: Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

4. The nurse is taking care of a child who had a tonsillectomy. The nurse should observe the child for which of the following during the postoperative period?

1. Dehydration 2. Arrhythmias 3. Increased blood sugar 4. Increased urinary output Correct answer: 1 Rationale: 1. The child is at risk for dehydration due to deficient fluid volume related to inadequate intake after surgery. The child will anticipate having pain if she tries to swallow.

2. Unless the child has a heart condition prior to surgery, arrhythmias is not a possible postoperative complication 3. Increased blood sugar will result only if the child is a diabetic.

4. Increased urinary output is not an expected complication of surgery.

Cognitive Level: Application Client Need: Health Promotion and Maintenance

Nursing Process: Diagnosis Learning Outcome 24-2: Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

5. The nurse is admitting a patient to the adolescent unit. During the history and physical, the nurse records the following symptoms: abrupt onset, tonsillar exudate, painful cervical lymphadenopathy, anorexia, nausea, vomiting, abdominal pain, severe sore throat, headache, malaise, fever, and petechial mottling of soft palate. The nurse suspects the patient has which of the following?

1. Viral pharyngitis 2. Tonsillitis 3. Pharyngitis caused by group A beta-hemolytic streptococcus 4. Adenoiditis Correct answer: 3 Rationale: 1. Viral pharyngitis might have some of the symptoms but does not have petechial mottling of the soft palate.

2. Tonsillitis will have some of the symptoms but will not have petechial mottling of the soft palate, painful cervical lymphadenopathy, or severe sore throat.

3. Strep throat will have all of the above symptoms.

4. The adenoids are lymphatic tissue located on the posterior pharyngeal wall, and are sometime called the pharyngeal tonsils. They can manifest with acute or chronic infection.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome 24-2: Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

6. A nurse is assessing infants for visually related developmental milestones. The infant who is showing a delay in meeting an expected milestone is the: 1. 4-month-old who has a social smile.

2. 7-month-old who picks up a raisin by raking.

3. 8-month-old who has just begun to inspect her own hand.

4. 12-month-old who stacks blocks.

Correct answer: 3 Rationale: 1. A 4-month-old with a social smile is showing appropriate visually related milestones.

2. A 7-month-old who picks up raisins by raking is showing appropriate visually related milestones.

3. An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months.

4. A 12-month-old who stacks blocks is showing appropriate visually related milestones.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 24-3: Plan for screening programs and identification of children with vision and hearing abnormalities.

7. The nurse suspects that an infant has a visual disorder caused by abnormal musculature. To detect this disorder, the nurse would perform: 1. A cover/uncover test.

2. An ophthalmologic exam.

3. A vision acuity exam.

4.

A pupil-reaction-to-light test.

Correct answer: 1 Rationale: 1. The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. The cover/uncover test can be used to test for eye muscle weakness in children. Unexpected movement of one eye indicates a muscle imbalance.

2. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature.

3. Vision acuity is used to test for myopia.

4. Pupil-reaction-to-light tests neurological status.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 24-3: Plan for screening programs and identification of children with vision and hearing abnormalities.

8. The nurse is caring for a child who had a cochlear implant. Which of the following is most important for the parents to follow up with?

1. Sign language therapy

2. Speech therapy 3. Child life therapy 4. Occupational therapy Correct answer: 2 Rationale: 1. Although the child might need sign language, following cochlear implant, this is not the most important therapy.

2. Children with cochlear implants need regular speech therapy after surgery due to the increased rate of bacterial meningitis in the cochlear recipient.

3. Child life therapy is not the most important at this time 4. The child does not need to work with occupational therapy at this time.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Application Learning Outcome 24-3: Plan for screening programs and identification of children with vision and hearing abnormalities.

9. A neonate has been diagnosed with a herpes simplex viral infection of the eye. The nurse will prepare to administer: 1. Fluoroquinolone eyedrops or ointment.

2. Intravenous penicillin.

3. Oral erythromycin.

4.

Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment.

Correct answer: 4

Rationale: 1. Fluoroquinolone eyedrops are used to treat bacterial eye infections.

2. Intravenous penicillin treats selected bacterial infections.

3. Oral erythromycin is used to treat Chlamydial eye infections.

4. Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine).

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 24-4: Plan comprehensive nursing care for children with vision and hearing impairment.

10. A nurse is caring for a visually impaired 20-month-old who has not begun to walk. An appropriate nursing diagnosis for this child would be: 1. Delayed growth and development.

2. Impaired physical mobility.

3. Self-care deficit.

4.

Impaired home maintenance.

Correct answer: 1 Rationale: 1. A 20-month-old child who is not walking is delayed in growth and development.

Toddlers generally walk by 15 months of age.

2. The child’s mobility is not due to a physiological problem, so impaired mobility is not

appropriate.

3. Self-care deficit does not apply to this age of child.

4. There are not enough data to determine if home maintenance is impaired.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome 24-4: Plan comprehensive nursing care for children with vision and hearing impairment.

11. A nurse is caring for a visually impaired 10-year-old child. The nursing intervention with the highest priority for this child during the admission process would be: 1. Explaining playroom policies.

2. Orienting the child to where furniture is placed in the room.

3. Letting the child touch equipment that will be used during the hospitalization.

4.

Taking the child on a tour of the unit.

Correct answer: 2 Rationale: 1. Policies can be covered at a later time 2. The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client.

3. Handling equipment can be covered at a later time.

4. Tours can be done at a later time.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment Nursing Process: Implementation

Learning Outcome 24-4: Plan comprehensive nursing care for children with vision and hearing impairment.

12. An infant has acute otitis media. Which of the following would be the most important for the nurse to teach the parents?

1. Keep the baby in a flat position during sleep.

2. Administer acetaminophen (Tylenol) to relieve discomfort.

3. Administer a decongestant.

4.

Place the baby to sleep with a pacifier.

Correct answer: 2 Rationale: 1. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended.

2. An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media.

3. Decongestants are not recommended for treatment of acute otitis media.

4. Placing infants to sleep with a pacifier can increase the incidence of otitis media.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation

Learning Outcome 24-5: Apply current recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

The nurse has taught a group of parents how to care for their children who have just had 13. tympanostomy tubes inserted. The nurse will know the parents understand how to care for their child’s tympanostomy tubes if they: (Select all that apply.)

1. Encourage the children to drink generous amounts of fluids.

2. Administer a decongestant for 1–2 weeks following surgery.

3. Restrict the children to quiet activities after surgery.

4. Limit their diets to soft, bland foods.

5.

Avoid getting water in their ears during bath time.

Correct answer: 1, 3, 5 Rationale: 1. The correct responses include encouraging the children to drink generous amounts of water, restricting the children to quiet activities after surgery, and avoiding water in the children’s ears at bath time.

2. Incorrect responses include administering a decongestant for 1–2 weeks following surgery and limiting their diets to soft, bland foods.

3. The correct responses include encouraging the children to drink generous amounts of water, restricting the children to quiet activities after surgery, and avoiding water in the children’s ears at bath time.

4. Limiting the diet to soft, bland foods and administering decongestants are not needed after surgery. A regular diet should be resumed.

5. The correct responses include encouraging the children to drink generous amounts of water, restricting the children to quiet activities after surgery, and avoiding water in the children’s ears at bath time.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 24-5: Apply current recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

14.

The nurse can assist a child who has a mild hearing loss and reads lips to adapt to

hospitalization by: 1. Speaking directly to the parents for communication.

2. Speaking in a loud voice while facing the child.

3. Using a picture board as the main means of communication.

4.

Touching the child lightly before speaking

Correct answer: 4 Rationale: 1. Speaking to only the parents does not help the child with the hospitalization.

2. Speaking in a loud voice might not promote hearing in the child.

3. Picture boards, while useful, should not be the primary means of communication for a child who reads lips.

4. The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lipread by obtaining the child’s visual attention by lightly touching the child before communicating.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation

Learning Outcome 24-5: Apply current recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

15. A school child has epistaxis. The school nurse appropriately intervenes by: 1. Tilting the child’s head forward, squeezing the nares below the nasal bone, and applying ice to the nose.

2. Tilting the child’s head back, squeezing the bridge of the nose, and applying a warm moist pack to the nose.

3. Lying the child down and applying no pressure or ice or warm pack.

4.

Immediately packing the nares with a cotton ball soaked with Neo-Synephrine

Correct answer: 1 Rationale: 1. The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10–15 minutes, and apply ice to the nose or back of the head.

2. Tilting the child’s head back could cause the blood to trickle down the throat. Warmth can cause an increase in bleeding because of vasodilation.

3. Lying the child down without application of pressure to the nares might not stop the bleeding.

4. A cotton ball soaked with Neo-Synephrine would only be used if the bleeding did not stop with pressure and ice.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation

Learning Outcome 24-5: Apply current recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

16. The nurse has completed postoperative discharge teaching to the parents of a child who has had a tonsillectomy. The nurse will know the parents understand the teaching if they state: 1. “We will call the physician for any indication of ear pain.”

2. “We will plan on administering acetaminophen (Tylenol) for pain.”

3. “We will be sure to give our child adequate amounts of citrus juices.”

4.

“We will keep our child on bedrest for ten days after the surgery.”

Correct answer: 2 Rationale: 1. Ear pain 4–8 days after a tonsillectomy might be experienced, and does not indicate an ear infection.

2. Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy.

3. Citrus juices should be avoided for the first week, because highly acidic foods and beverages can cause irritation.

4. Children do not need to be confined to bed. They can return to school in 10 days.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 24-5: Apply current recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

17. A nurse who is planning to teach school-age children about the “common cold” should include the information that: 1. Vaccinations can prevent contraction of a nasopharyngitis virus.

2. Antibiotics will eliminate the nasopharyngitis virus.

3. Proper handwashing can prevent the spread of the common cold.

4. Aspirin should be taken for alleviation of fever if the common cold is contracted.

Correct answer: 3 Rationale: 1. No vaccine can prevent the common cold.

2. Antibiotics are not used to treat viral infections.

3. Proper handwashing should be taught to school-age children to reduce the spread of the “common cold” virus.

4. Aspirin should not be taken for fever, because of its association with Reye’s syndrome.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome 24-6: Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

18. A child has been diagnosed with group A beta-hemolytic streptococcus (GABHS) infection of the throat. The nurse should teach the parents to: 1. Complete the entire course of antibiotics.

2. Keep the child n.p.o. (nothing by mouth).

3. Continue normal activities.

4. Not allow the child to gargle with salt water.

Correct answer: 1 1. It is important for parents to complete the entire course of antibiotics for GABHS infections.

2. Nothing-by-mouth, or n.p.o., status is not recommended, because the child needs to stay hydrated.

3. The child should rest.

4. Warm salt water gargling is recommended.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 24-6: Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Ball and Bindler

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1. A toddler has had recurrent respiratory infections. The mother of the child expressed concern that her infant seemed to be at increased risk for complications from infection in comparison with her older children. The best response from the nurse would be: 1. “Air passages are more likely to become blocked with mucus because younger children make more mucus than do older children.”

2. “Toddlers do not breathe as deeply as do older children.”

3. “You are incorrect in her assessment.”

4. “Airways are smaller and more easily occluded in the younger child.”

Answer: 4 Rationale: 1. Blockage of air passages with mucus is not related to the age of the child, but more to etiology of production of mucus and continuation of the causative agent.

2. Depth of breathing is not age-dependent.

3. The mother is correct in her statement.

4. Airways are smaller with the younger child, and are more easily occluded when mucus is produced.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 25.1 Describe unique characteristics of the pediatric respiratory system anatomy and physiology, and apply that information to the care of children with respiratory conditions.

2. Nursing assessment of the child’s respiratory system must be done quickly because of which of the following?

1. The child is more vulnerable to allergic reactions.

2. The child is more prone to aspiration.

3. Airways are less reactive than those of an adult.

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4. Airways are less prone to obstruction in the child.

5. Airways are smaller, with resulting resistance as air moves through the airway.

Answer: 1, 2, 5 Rationale: 1. The child is more vulnerable to allergic reactions because the airways are smaller and more easily obstructed when inflamed or blocked with the mucus produced from an allergic reaction.

2. The child is more prone to aspiration because the larynx and glottis are higher in the neck.

3. Airways are more reactive than those of an adult due to size and ability to obstruct.

4. Airways are more prone to obstruction because they are smaller and more easily occluded with infection.

5. Airways are smaller and resistance is greater in the child.

Cognitive Level: Assessment Client Need: Physiological Integrity Nursing Process: Application Learning Outcome 25.1 Describe unique characteristics of the pediatric respiratory system anatomy and physiology, and apply that information to the care of children with respiratory conditions.

3. A child is showing signs of acute respiratory distress. The child should be positioned: 1. Upright.

2. Side-lying.

3. Flat.

4.

In semi-Fowlers.

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Rationale: 1. Upright is correct because it allows for optimal chest expansion.

2. Side-lying, flat, and semi-Fowler’s (head up slightly) do not allow for optimal chest expansion, as does the upright position.

3. Side-lying, flat, and semi-Fowler’s (head up slightly) do not allow for optimal chest expansion, as does the upright position.

4. Side-lying, flat, and semi-Fowler’s (head up slightly) do not allow for optimal chest expansion, as does the upright position.

Implementation Physiological Integrity Application Learning Outcome 25.1 Describe unique characteristics of the pediatric respiratory system anatomy and physiology, and apply that information to the care of children with respiratory conditions.

4. A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). The nurse should be prepared to: 1. Administer nebulized epinephrine and oral or IM dexamethasone.

2. Administer antibiotics and assist with possible intubation.

3. Swab the throat for a throat culture.

4.

Obtain a sputum specimen.

Answer: 1 Rationale: 1. Nebulized epinephrine and dexamethasone are given for LTB. 2. Antibiotic administration and possible intubation are associated with epiglottitis.

3. Throat cultures are not obtained for LTB, because it is viral, and swabbing the throat 3of 18

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could cause complete obstruction to occur.

4. Sputum specimens will not assist in the diagnosis of LTB. Planning Physiological Integrity Analysis Learning Outcome 25.2 Describe the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

5. A child is admitted with epiglottitis, and needs a radiograph. The nurse orders the radiograph to be done by: 1. Transporting the child to the Radiography department.

2. Portable radiograph in the unit’s waiting room.

3. Portable radiograph in the child’s hospital room.

4.

Transporting the child to the Radiography department in a parent’s arms.

Answer: 3 Rationale: 1. Traveling to the Radiography department takes the child away from emergency equipment and trained personnel.

2. Traveling to the unit’s waiting room takes the child away from emergency equipment and trained personnel.

3. The radiograph should be portable so that the child remains on the pediatric unit near equipment and personnel who can perform emergency airway interventions.

4. Traveling to the Radiography department takes the child away from emergency equipment and trained personnel.

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Implementation Safe, Effective Care Environment Application Learning Outcome 25.2 Describe the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

6. A nurse is assessing a neonate. The assessment that might indicate that the neonate’s respiratory status is worsening is: 1. Acrocyanosis.

2. Arterial CO2 of 40.

3. Periorbital edema.

4.

Grunting respirations with nasal flaring.

Answer: 4 Rationale: 1. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate.

2. CO2 of 40 is within normal range. 3. Periorbital edema does not necessarily mean deterioration in respiratory status. 4. Grunting respirations with nasal flaring indicate respiratory status is becoming worse. Assessment Physiological Integrity Analysis Learning Outcome 25.2 Describe the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

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7. A nurse delegates the task of neonatal vital sign assessment to a nurse technician. The nurse should instruct the technician to: 1. Report any neonate using abdominal muscles to breathe.

2. Report any neonate with apnea for 10 seconds.

3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.

4.

Report any neonate with a breathing pause that lasts 20 seconds or longer.

Answer: 4 Rationale: 1. It’s normal for neonates to use abdominal muscles for breathing.

2. A breathing pause of 10 seconds or less is called periodic breathing, and is a normal pattern for a neonate.

3. Respirations should be counted for 1 minute, not 15 seconds.

4. The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds.

This can indicate apnea, and could lead to an apparent life-threatening event (ALTE).

Assessment Safe, Effective Care Environment Analysis Learning Outcome 25.3 Assess the child’s respiratory signs and symptoms to distinguish between mild, moderate, and severe respiratory distress, and identify the appropriate nursing actions for each level of severity.

8. An appropriate nursing diagnosis for an infant with acute bronchiolitis due to

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respiratory syncytial virus (RSV) would be: 1. Activity intolerance.

2. Decreased cardiac output.

3. Pain, acute.

4.

Tissue perfusion, ineffective (peripheral).

Answer: 1 Rationale: 1. Activity intolerance is a problem because of the imbalance between oxygen supply and demand.

2. Cardiac output is not compromised during an acute phase of bronchiolitis.

3. Pain is not usually associated with acute bronchiolitis.

4. Tissue perfusion (peripheral) is not affected by this respiratory disease process.

Diagnosis Physiological Integrity Analysis Learning Outcome 25.3 Assess the child’s respiratory signs and symptoms to distinguish between mild, moderate, and severe respiratory distress, and identify the appropriate nursing actions for each level of severity.

9. A child is admitted to the hospital with pneumonia. The child’s oximetry reading is 88% upon admission to the Pediatric floor. The priority nursing activity for this child would be to: 1. Obtain a blood sample to send to the lab for electrolyte analysis.

2. Begin oxygen per nasal cannula at 1 liter.

3. Medicate for pain.

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Begin administration of intravenous fluids.

Answer: 2 Rationale: 1. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child’s oxygenation status has been addressed.

2. Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula at 1 liter should be started initially.

3. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child’s oxygenation status has been addressed.

4. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child’s oxygenation status has been addressed.

Implementation Safe, Effective Care Environment Application Learning Outcome 25.3 Assess the child’s respiratory signs and symptoms to distinguish between mild, moderate, and severe respiratory distress, and identify the appropriate nursing actions for each level of severity.

10. A 2-year-old male child arrived in the Emergency Department with complaints of sore throat, difficulty swallowing, and suspected diagnosis of acute epiglottitis. Which of the following interventions should not be included in the child’s immediate care and assessment?

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1. Vital signs 2. Medical history 3. Assessment of breath sounds 4. Throat culture

Answer: 4 Rationale: 1. Vital signs should always be taken when assessment is done.

2. Medical history should be obtained, which assists in diagnosis.

3. Assessment of breath sounds is essential for diagnosis.

4. Throat culture should never be done when a diagnosis of epiglottis is suspected.

Manipulation of the throat can stimulate the gag reflex in an already inflamed airway, and can cause complete occlusion of the airway.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 25.3 Assess the child’s respiratory signs and symptoms to distinguish between mild, moderate, and severe respiratory distress, and identify the appropriate nursing actions for each level of severity.

11. Which of the following statements is true of apnea?

1. The etiology is sometimes unknown.

2. Apnea results in sudden death for the child.

3. It resolves spontaneously within one week.

4. It is treated with antibiotics.

Answer: 1 Rationale:

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1. Apnea can be associated with other disease states or stand alone with unknown etiology.

2. Apnea is not associated with sudden death.

3. It does not resolve within one week.

4. Apnea is not treated with antibiotics.

Cognitive Level: Comprehension Client Need: Physiological Adaptation Nursing Process: Diagnosis Learning Outcome 25.4 Differentiate between different causes of apnea in infants and children, and identify nursing actions appropriate for each.

12. Which of the following suggests theophylline toxicity in the infant treated for central apnea?

1. Nausea and vomiting 2. Bradycardia 3. Seizures 4. Decreased alertness

Answer: 1 Rationale: 1. Theophylline toxicity does result in nausea and vomiting for the child.

2. Tachycardia is a result of theophylline toxicity.

3. Seizures are not associated with theophylline toxicity.

4. Decreased alertness is not related to theophylline toxicity.

Cognitive Level: Comprehension Client Need: Physiological Adaptation Nursing Process: Assessment

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Learning Outcome 25.4 Differentiate between different causes of apnea in infants and children, and identify nursing actions appropriate for each.

13. Supportive care for the family of an infant who died from sudden infant death syndrome (SIDS) includes: 1. Interviewing parents to determine the cause of the SIDS incident.

2. Allowing parents to hold, touch, and rock the infant.

3. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints.

4.

Advising parents that an autopsy is not necessary.

Answer: 2 Rationale: 1. The other options are nontherapeutic.

2. The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby.

3. The other options are nontherapeutic.

4. The death of an infant without a known medical condition is an indication for an autopsy.

Implementation Psychosocial Integrity Application Learning Outcome 25.4 Differentiate between different causes of apnea in infants and children, and identify nursing actions appropriate for each.

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14. The nurse is teaching a group of mothers of infants about the benefits of immunization. The nurse will explain that the life-threatening disease epiglottitis can be prevented by immunization against: 1. Measles, mumps, and rubella (MMR).

2. Haemophilus influenzae type B (HIB).

3. Hepatitis B. 4.

Polio.

Answer: 2 Rationale: 1. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

2. The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis.

3. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

4. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Planning Health Promotion and Maintenance Analysis Learning Outcome 25.5 Synthesize information and develop a hospital-based nursing care plan in partnership with the family for a child with a common acute respiratory condition.

15. A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the

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clinic and report that the child’s urine is orange. The nurse should advise the parents to: 1. Bring the child to the clinic for a urinalysis.

2. Bring the child to the clinic for an radiograph of the kidneys.

3. Expect orange-colored urine while the child is on rifampin.

4.

Encourage the child to drink cranberry juice.

Answer: 3 Rationale: 1. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

2. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

3. Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect.

4. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

Implementation Physiological Integrity Application Learning Outcome 25.5 Synthesize information and develop a hospital-based nursing care plan in partnership with the family for a child with a common acute respiratory condition.

16. The physician has changed the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse should explain that salmeterol (Serevent) is used to treat asthma because the drug:

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1. Is an anti-inflammatory.

2. Decreases mucus production.

3. Controls allergic rhinitis.

4.

Is a bronchodilator.

Answer: 4 Rationale: 1. Steroids are anti-inflammatory, anticholinergics decrease mucus production, and antihistamines control allergic rhinitis.

2. Steroids are anti-inflammatory, anticholinergics decrease mucus production, and antihistamines control allergic rhinitis.

3. Steroids are anti-inflammatory, anticholinergics decrease mucus production, and antihistamines control allergic rhinitis.

4. Salmeterol (Serevent) is a long-acting beta-2-agonist that acts by bronchodilating.

Implementation Physiological Integrity Analysis Learning Outcome 25.5 Synthesize information and develop a hospital-based nursing care plan in partnership with the family for a child with a common acute respiratory condition.

17. A child with asthma will be receiving an oral dose of prednisone. The order reads: Prednisone 2 mg/kg per day. The child weighs 50 pounds. How many mg will the child receive daily? (Round the answer to the nearest tenth.)

Write in your answer: ___________ Answer: 45.5

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Rationale: 50 pounds/2.2 = 22.7 22.7  2 = 45.5 Implementation Physiological Integrity Analysis Learning Outcome 25.5 Synthesize information and develop a hospital-based nursing care plan in partnership with the family for a child with a common acute respiratory condition.

18. Following parental teaching, the nurse is evaluating the parent’s understanding of environmental control for their child’s asthma management. Teaching has been understood by the parents if they state: 1. “We will replace the carpet in our child’s bedroom with tile.”

2. “We’re glad the dog can continue to sleep in our child’s room.”

3. “We’ll be sure to use the fireplace often to keep the house warm in the winter.”

4.

“We’ll keep the plants in our child’s room dusted.”

Answer: 1 Rationale: 1. Control of dust in the child’s bedroom is an important aspect of environmental control for asthma management.

2. When possible, pets and plants should not be kept in the home.

3. Smoke from fireplaces should be eliminated.

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4. When possible, pets and plants should not be kept in the home.

Evaluation Health Promotion and Maintenance Analysis Learning Outcome 25.6 Synthesize information and develop a home nursing care plan in partnership with the family for the child with a chronic respiratory condition.

19. A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse what symptoms made the physician suspect cystic fibrosis. The nurse would reply that the clinical manifestation of cystic fibrosis that is seen first is: 1. Steatorrheic stools.

2. Constipation.

3. Meconium ileus.

4.

Rectal prolapse.

Answer: 3 Rationale: 1. Steatorrhea, constipation, and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child.

2. Steatorrhea, constipation, and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child.

3. Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus.

4. Steatorrhea, constipation, and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child.

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Assessment Physiological Integrity Analysis Learning Outcome 25.6 Synthesize information and develop a home nursing care plan in partnership with the family for the child with a chronic respiratory condition.

20. The nurse is teaching the parents of a newly diagnosed cystic fibrosis patient how to administer the pancreatic enzymes. The nurse will advise the parents to administer the enzymes: 1. b.i.d. (twice daily).

2. With meals and snacks.

3. Every six hours around the clock.

4.

q.i.d. (four times daily).

Answer: 2 Rationale: 1. A scheduled time would not be appropriate, because the enzymes are used to assist in digestion of nutrients.

2. Pancreatic enzymes are administered with meals and large snacks.

3. A scheduled time would not be appropriate, because the enzymes are used to assist in digestion of nutrients.

4. A scheduled time would not be appropriate, because the enzymes are used to assist in digestion of nutrients.

Implementation Physiological Integrity Application

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Learning Outcome 25.6 Synthesize information and develop a home nursing care plan in partnership with the family for the child with a chronic respiratory condition.

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1. Which of the following structures are classified as fetal shunts? Select all that apply.

1. The coronary sinus 2. The tricuspid valve 3. The foramen ovale 4. The ductus arteriosus Answer: 3, 4 Rationale: 1. The coronary sinus is not a fetal shunt.

2. The tricuspid valve empties blood from the right atrium into the right ventricle.

3. The foramen ovale shunts blood into the left side of the heart for distribution systemically in fetal life.

4. The ductus arteriosus shunts blood from the high-pressure lungs from the pulmonary artery into the aorta for systemic distribution during fetal life.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 26-1 Describe the transition from fetal to pulmonary circulation.

2. Which congenital cardiac defect is the foramen ovale classified as if it fails to close after the infant transitions from fetal circulation to pulmonary circulation?

1. A ventricular septal defect 2. A coarctation of the aorta 3. An atrial septal defect 4. A complete atrioventricular canal Answer: 3 Rationale: 1. A ventricular septal defect is an opening between the right and left ventricle, and is not in the location of the foramen ovale.

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2. A coarctation of the aorta is a narrowing in the descending aorta.

3. Atrial septal defect is the resulting defect if the foramen ovale remains open.

4. An atrioventricular canal involves an atrial septal defect that connects with a ventricular septal defect, and is lower in the atrial septum than the foramen ovale.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 26-1 Describe the transition from fetal to pulmonary circulation.

3. If the ductus arteriosus remains patent in extrauterine life, nursing care will be directed toward management of which of the following problems?

1. Increased pulmonary blood flow 2. Decreased pulmonary blood flow 3. Decreased cardiac output 4. Both increased pulmonary blood flow and decreased cardiac output Answer: 4 Rationale: 1. If there is a patent ductus arteriosus (PDA), systemic blood flow will be shunted back into the lungs through the patent ductus from the high-pressure aorta into the lower pressure lungs. This will also result in decreased cardiac output.

2. The presence of a PDA will increase pulmonary blood flow.

3. If there is a PDA, cardiac output will decrease, but pulmonary blood flow will be also be increased.

4. Both increased pulmonary blood flow and decreased cardiac output will result with a PDA. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 26-1 Describe the transition from fetal to pulmonary circulation.

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4. The nurse is checking peripheral perfusion to a child’s extremity following a cardiac

catheterization. If there is adequate peripheral circulation, the nurse would find that the extremity: 1. Has a capillary refill of greater than three seconds.

2. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.

3. Has decreased sensation with a weakened dorsalis pedis pulse.

4.

Is warm, with a capillary refill of less than three seconds.

Answer: 4 Rationale: 1. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.

2. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.

3. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.

4. The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color.

Assessment Physiological Integrity Analysis

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Learning Outcome 26.2 List three differences in cardiac functioning between infants and adults.

5. Cardiac output in children under the age of 5 years is dependent on which of the following factors?

1. Heart rate 2. Preload 3. Contractility 4. Afterload Answer: 1 Rationale: 1. Cardiac output in newborns and young children depends primarily on heart rate until the heart muscle is fully developed at 5 years of age.

2. The undeveloped muscle fibers in the myocardium are unable to expand their stretch to increase the ventricular volume or preload.

3. The heart muscle fibers are unable to expand until age 5.

4. The heart muscle is not fully developed until age 5, and cannot alter afterload effectively.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 26-2 List three differences in cardiac functioning between infants and adults.

6. During the newborn assessment, a systolic blood pressure that is higher in the legs than in the arms is suggestive of which of the following findings?

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1. Cardiac arrhythmia 2. Coarctation of the aorta 3. Chromosome abnormality 4. A normal finding for an infant Answer: 4 Rationale: 1. A cardiac arrhythmia would decrease cardiac output, and would result in lower pressure in all extremities.

2. Coarctation of the aorta would result in lower pressures in the legs than in the arms.

3. A chromosomal abnormality would not be directly associated with blood pressure differences.

4. This is a normal finding in the child, because blood takes the path of least resistance, making pressures lower in the arms than legs.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 26-2 List three differences in cardiac functioning between infants and adults.

7. The nurse has admitted a child with a cyanotic heart defect. The nurse would expect the initial lab result to show: 1. A high hemoglobin.

2. A low hematocrit.

3. A high white blood cell count.

4.

A low platelet count.

Answer: 1 Rationale: 1. The child’s bone marrow responds to chronic hypoxemia by producing more red blood

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cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects.

2. The hematocrit would not be low.

3. The white blood cell count would not be high unless an infection were present.

4. The platelets would be normal.

Assessment Physiological Integrity Analysis Learning Outcome 26.3 Describe the pathophysiology associated with congenital heart defects associated with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

8. The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. An appropriate nursing diagnosis for this child is: 1. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow.

2. Deficient fluid volume related to hyperthermia secondary to the congenital heart defect.

3. Acute pain related to the effects of a congenital heart defect.

4.

Hypothermia related to decreased metabolic state.

Answer: 1 Rationale: 1. Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.

2. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

3. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

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4. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Diagnosis Physiological Integrity Analysis Learning Outcome 26.3 Describe the pathophysiology associated with congenital heart defects associated with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

9. The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities, and higher blood pressure readings in the arms than in the legs. This could be indicative of what heart defect?

1. Patent ductus arteriosus 2. Atrial septal defect 3. Transposition of the great vessels 4.

Coarctation of the aorta

Answer: 4 Rationale: 1. These defects are not associated with blood pressures that are different in upper and lower extremities.

2. These defects are not associated with blood pressures that are different in upper and lower extremities.

3. These defects are not associated with blood pressures that are different in upper and lower extremities.

4. Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs

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because of obstruction of circulation to the lower extremities.

Assessment Physiological Integrity Analysis Learning Outcome 26.3 Describe the pathophysiology associated with congenital heart defects associated with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

10. An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode (“tet” spell). Which of the following nursing interventions should the nurse implement? Select all that apply.

1. Place the child in knee–chest position.

2. Draw blood for a serum hemoglobin.

3. Administer oxygen.

4. Administer morphine and propranolol intravenously as ordered.

5.

Administer Benadryl as ordered.

Answer: 1, 3, 4 Rationale: 1. When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance.

Therefore, the nurse would place the infant in knee–chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).

2. The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed.

3. When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode,

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interventions should be geared toward decreasing the pulmonary vascular resistance.

Therefore, the nurse would place the infant in knee–chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).

4. When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance.

Therefore, the nurse would place the infant in knee–chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).

5. Benadryl is not appropriate for this child.

Implementation Safe, Effective Care Environment Application Learning Outcome 26.4 Develop a nursing care plan for the child with a congenital heart defect cared for at home prior to corrective surgery.

11. An infant has been diagnosed with a mild cyanotic heart defect. Surgery to correct the defect will not be performed for at least two years. The nurse teaches the parents that a child with a mild cyanotic heart defect should: 1. Maintain normal activity.

2. Be placed on bedrest.

3. Not be given antipyretics.

4.

Have a low-grade fever until the defect is repaired.

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without activity adjustment.

2. Bedrest would not be recommended.

3. Fevers are treated with antipyretics so that dehydration is avoided.

4. Low-grade fever is not a normal finding in a child with a mild cyanotic heart defect, and could be a sign of infective endocarditis.

Implementation Health Promotion and Maintenance Application Learning Outcome 26.4 Develop a nursing care plan for the child with a congenital heart defect cared for at home prior to corrective surgery.

12. Which of the following would be included in nursing care of the infant with congestive heart failure?

1. Force fluids appropriate for age.

2. Monitor respirations during active periods.

3. Organize activities to allow for uninterrupted sleep.

4. Give larger feedings less often to conserve energy.

Answer: 3 Rationale: 1. Fluids should be restricted to high-calorie and low-volume in order to avoid overloading the lungs with fluid.

2. Respirations are difficult to monitor during active periods, making this an unrealistic goal.

3. It is important to allow for uninterrupted sleep to decrease metabolic demands on the heart.

4. Feedings should be small-volume, high-calorie.

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Cognitive Level: Synthesis Client Need: Physiological Adaptation Nursing Process: Planning Learning Outcome: 26-4 Develop a nursing care plan for the child with a congenital heart defect cared for at home prior to corrective surgery.

13. A toddler has been started on digoxin (Lanoxin) for cardiac failure. If the child develops digoxin (Lanoxin) toxicity, the first sign the nurse might note would be: 1. Lowered blood pressure.

2. Tinnitus.

3. Ataxia.

4.

Nausea and vomiting.

Answer: 4 Rationale: 1. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

2. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

3. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

4. An early sign of digoxin (Lanoxin) toxicity is nausea and vomiting.

Assessment Physiological Integrity Analysis Learning Outcome 26.5 Develop a nursing care plan for the child undergoing open heart surgery.

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14. The nurse is teaching the parents of a group of cardiac patients. The nurse includes in the information that any child who has undergone cardiac surgery: 1. Should be restricted from most play activities.

2. Should receive prophylactic antibiotics for any dental, oral, or upper respiratory tract procedures.

3. Should not receive routine immunizations.

4.

Can be expected to have a fever for several weeks following the surgery.

Answer: 2 Rationale: 1. The child should live a normal and active life following repair of a cardiac defect.

2. Parents should be taught that the child should receive prophylactic antibiotics, according to the American Heart Association, to prevent endocarditis.

3. Immunizations should be provided according to the schedule.

4. Fever is not expected for a prolonged period after surgery, and any unexplained fever should be reported.

Implementation Health Promotion and Maintenance Application Learning Outcome 26.5 Develop a nursing care plan for the child undergoing open heart surgery.

15. A child has had a heart transplant. The nurse recognizes that postoperative teaching has been successful when the parents state that the child is on cyclosporin A to: 1. Reduce serum cholesterol level.

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2. Prevent rejection.

3. Treat hypertension.

4.

Treat infections.

Answer: 2 Rationale: 1. Lovastatin is given to reduce serum cholesterol level.

2. Cyclosporin A is given to prevent rejection.

3. Calcium channel blockers may be used to treat hypertension.

4. An antibiotic may be given to treat an infection.

Evaluation Physiological Care Analysis Learning Outcome 26.5 Develop a nursing care plan for the child undergoing open heart surgery.

16. A child has been admitted to the hospital unit in congestive heart failure (CHF).

Symptoms related to this admission diagnosis would include: 1. Weight loss.

2. Bradycardia.

3. Tachycardia.

4.

Increased blood pressure.

Answer: 3 Rationale: 1. The weight, instead of decreasing, increases, because of retention of fluids.

2. Bradycardia is a serious sign, and can indicate impending cardiac arrest.

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3. Tachycardia is a sign of congestive heart failure, because the heart attempts to improve cardiac output by beating faster.

4. Blood pressure does not increase in CHF.

Assessment Physiological Integrity Analysis Learning Outcome 26.6 Recognize the signs and symptoms of congestive heart failure in infants and children, and develop a nursing care plan.

17. The mother of a child with a heart defect is questioning the nurse about the child’s medication. The nurse explains that spironolactone (Aldactone) is a diuretic that: 1. Spares potassium.

2. Produces rapid diuresis.

3. Blocks reabsorption of sodium and water in renal tubules.

4.

Promotes vascular relaxation.

Answer: 1 Rationale: 1. Spironolactone (Aldactone) is a maintenance diuretic that is potassiumsparing.

2. Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules.

3. Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules.

4. ACE inhibitors promote vascular relaxation.

Implementation Physiological Integrity

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Application Learning Outcome 26.6 Recognize the signs and symptoms of congestive heart failure in infants and children, and develop a nursing care plan.

18. A diagnosis of rheumatic fever is being ruled out for a child. The nurse teaches the parents that the lab test to check for a recent streptococcal infection is: 1. Throat culture.

2. Antistreptolysin-O (ASLO) titer.

3. Erythrocyte sedimentation rate.

4.

C-reactive protein.

Answer: 2 Rationale: 1. A culture can indicate a current streptococcal infection.

2. The lab test for antistreptococcal antibodies is an antistreptolysin-O (ASLO) titer.

3. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation.

4. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation.

Assessment Physiological Integrity Analysis Learning Outcome 26.6 Recognize the signs and symptoms of congestive heart failure in infants and children, and develop a nursing care plan.

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19. An athletic activity the nurse could recommend for a school-age child with pulmonary-artery hypertension is: 1. Cross-country running.

2. Soccer.

3. Golf.

4.

Basketball.

Answer: 3 Rationale: 1. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

2. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

3. A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea, such as golf.

4. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

Implementation Health Promotion and Maintenance Application Learning Outcome 26.7 Differentiate between acquired heart diseases that occur during childhood and congenital heart defects.

20. A child is admitted with infective endocarditis. The nurse is prepared to: 1. Start an intravenous line.

2. Place the child in contact isolation.

3. Place the child on seizure precautions.

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Assist with a lumbar puncture.

Answer: 1 Rationale: 1. Infective endocarditis is treated with intravenous antibiotics for 2–8 weeks. 2. Infective endocarditis is not contagious, so the child is not placed in contact isolation.

3. Seizures are not a risk of infective endocarditis.

4. A lumbar puncture is a diagnostic test performed for meningitis, not for infective endocarditis.

Planning Physiological Integrity Application Learning Outcome 26.7 Differentiate between acquired heart diseases that occur during childhood and congenital heart defects.

21. A nursing intervention for an unstable infant who has supraventricular tachycardia is: (Select all that apply.)

1. Application of ice to the face.

2. Administration of intravenous adenosine (Adenocard).

3. Administration of intravenous amiodarone (Cardarone).

4.

Preparation for cardioversion.

Answer: 2, 3, 4 Rationale: 1. Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face could reduce the heart rate.

2. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful.

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Cardioversion is used in an urgent situation.

3. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful.

Cardioversion is used in an urgent situation.

4. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful.

Cardioversion is used in an urgent situation.

Implementation Physiological Integrity Application Learning Outcome 26.7 Differentiate between acquired heart diseases that occur during childhood and congenital heart defects.

22. Which of the following are signs of early hypovolemic shock in children? Select all that apply.

1. Bradycardia 2. Increased work of breathing 3. Prolonged capillary refill time 4. Decreased blood pressure 5. Tachycardia Answer 2, 3, 5 Rationale: 1. Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate.

2. Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume.

3. Decreased capillary refill time would be an early indicator of decreased fluid volume and compensation.

4. Decreased blood pressure is a later finding, and would not occur until other compensatory mechanisms were exhausted.

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5. Tachycardia is an early compensatory mechanism for hypovolemia in a child.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 26-8 Describe the development of hypovolemic shock and nursing management of the condition.

23. Which of the following treatment measures would be given the highest priority for a child with hypovolemic shock?

1. Establish an open airway and administer oxygen.

2. Provide replacement of volume.

3. Administer analgesics for control of pain.

4. Assess the cause of bleeding.

Answer: 1 Rationale: 1. Airway patency and oxygen delivery (breathing) are always first in the treatment for a client with health concerns.

2. Replacement of volume is vital, but would follow establishing airway and breathing.

3. Pain would be a consideration, but would not be attended to as a first priority.

4. Airway patency and replacement of volume are priorities before assessing the cause of the bleeding.

Cognitive Level: Synthesis Client Need: Physiological Adaptation Nursing Process: Implementation Learning Outcome: 26-8 Describe the development of hypovolemic shock and nursing management of the condition.

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24. A child is admitted to the ED with a diagnosis of hypovolemic shock secondary to traumatic injury. Which of the following normal parental responses would the nurse expect to see?

1.

Somatic distress

2.

Feelings of guilt and negligence

3.

Violent patterns of conduct

4.

Confidence in a positive outcome for the child

Answer: 2 Rationale: 1. Somatic distress would occur later, but would not be evident in the ED. 2. Feelings of guilt and own negligence are normal, and would be expected.

3. The parents might exhibit stages of grief, including anger, but should not become violent.

4. Anxiety generally prohibits parents from seeing a positive outcome during the initial phase of stress and grief.

Cognitive Level: Evaluation Client Need: Psychological Integrity Nursing Process: Assessment Learning Outcome: 26-8 Describe the development of hypovolemic shock and nursing management of the condition.

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1. A parent of a newborn asks the nurse why young children seem to become ill so often when compared with older children and adults. Which of the following does the nurse’s best response address?

1. Lower numbers of natural killer cells 2. Underdeveloped thymus glands 3. High levels of IgA 4. Absent lymphoid tissue

Answer: 1 Rationale: 1. Newborns have lower numbers of natural killer cells than do older children and adults, decreasing their ability to respond to certain antigens.

2. The thymus is large at birth and grows during childhood, decreasing by adulthood.

3. IgA is not present at birth.

4. Lymphoid tissue, such as the spleen and tonsils, are present at birth.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 27-1 Describe the structure and function of the immune system, and apply knowledge to the care of children with immunologic function.

2. A premature infant is at greater risk for infection than are full-term infants because of a reduced number of which immunoglobulin?

1. IgE 2. IgG 3. IgM 4. IgA

Answer: 2 Rationale: 1. IgE does not cross the placenta, and is not present at birth in either preterm or full-term infants.

2. Maternal IgG crosses the placenta. Newborns’ levels are similar to their mothers’.

Premature infants have lower levels of IgG obtained from their mothers, and are at greater risk for infection.

3. IgM does not cross the placenta. The levels are low at birth in both preterm and fullterm infants.

4. IgA does not cross the placenta, and is not present at birth in either preterm or full-term infants.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 27-1 Describe the structure and function of the immune system, and apply knowledge to the care of children with immunologic function.

3. Children under age 6 years are at greater risk for infection due to underdeveloped: 1. Leukocytes.

2. Acquired immunity.

3. Natural immunity.

4. Antigens.

Answer: 2 Rationale: 1. Leukocytes are present at birth, and phagocytize foreign materials.

2. Acquired immunity, consisting of both humoral and cell-mediated immunity, is not fully developed until a child is 6 years of age. These include the processes responsible for destroying bacterial antigens through the production of antibodies.

3. Natural immunity is the defenses present at birth of intact skin, body pH, and antibodies obtained from the mother.

4. Antigens are the foreign substances that trigger the immune response.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 27-1 Describe the structure and function of the immune system, and apply knowledge to the care of children with immunologic function.

4. A nurse is planning care for a child with human immunodeficiency virus (HIV). Which of the following nursing diagnoses should take highest priority for this child?

1. Infection, risk for 2. Fluid volume deficit, risk for 3. Ineffective Thermoregulation 4. Ineffective Tissue Perfusion, peripheral

Answer: 1 Rationale: 1. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. 2. Risk for fluid volume deficit would not be a priority problem with this disease process. 3. Ineffective thermoregulation would not be a priority problem with this disease process. 4.

Ineffective tissue perfusion, peripheral would not be a priority problem with this disease process.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Diagnosis

Learning Outcome: 27-2 Identify infection-control measures to prevent the spread of infection in children with an immunodeficiency.

5. A child with human immunodeficiency virus is started on sulfamethoxazole and trimethoprim (Bactrim) for pneumocystis carinii pneumonia (PCP) prophylaxis. The recommended dose is based on the trimethoprim (TMP) component, and is 15–20 mg TMP/kg/day in divided doses every 6–8 hours. The child weighs 6.8 kg. What is the highest dose of TMP he can receive a day? _______________ mg

Answer: 136 Rationale: 6.8 multiplied by 20 mg is 136 mg a day.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 27-2 Identify infection-control measures to prevent the spread of infection in children with an immunodeficiency.

6. Which of the following immunizations should a child with acquired immune deficiency syndrome (AIDS) not receive?

1. Diphtheria and tetanus toxiods and acellular pertussis vaccine (DTaP) 2. Haemophilus influenzae type B (HIB conjugate vaccine) 3. Varicella vaccine 4. Hepatitis B vaccine (hep B)

Answer: 3 Rationale: 1. DTaP vaccinations are not a live vaccine, and should be given on schedule.

2. HIB vaccinations are not live vaccines, and should be given on schedule.

3. A child with an immune disorder should not be immunized with a live varicella vaccine, because of the risk of contracting the disease.

4. Hepatitis B vaccinations are not live vaccines, and should be given on schedule.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 27-2 Identify infection-control measures to prevent the spread of infection in children with an immunodeficiency.

7. Which of the following nursing diagnoses would the nurse anticipate for a family who has a child with acquired immune deficiency syndrome (AIDS)?

1. Anticipatory Grieving 2. Compromised Family Coping 3. Impaired Parenting, risk for 4. Parental Role Conflict

Answer: 1 Rationale: 1. AIDS is not curable, so the problem nurses can anticipate, for all families, is anticipatory grieving.

2. Compromised family coping might be present, but further information is needed to anticipate this problem.

3. Risk for impaired parenting might be present, but further information is needed to anticipate this problem.

4. Parental role conflict might be present, but further information is needed to anticipate this problem.

Cognitive Level: Analysis Client Need: Psychosocial Integrity

Nursing Process: Diagnosis Learning Outcome: 27-3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV) infection.

8. The nurse is planning to discharge a child with HIV infection. Which of the following discharge instruction should be included for this child and her family?

1. Avoid playing sports.

2. Restrict school attendance.

3. Cover open wounds.

4. Eat raw fruits.

Answer: 3 Rationale: 1. The child with HIV should participate in sports. While injuries are possible, it is unlikely that large quantities of blood will be present.

2. The majority of children with HIV can attend school without restrictions.

3. Wounds should be covered, and gloves should be worn when treating a child’s cuts and scrapes.

4. The child should avoid eating raw fruits and vegetables unless they are peeled, to decrease ingestion of microorganisms.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome: 27-3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV) infection.

9. The nurse caring for a child with HIV infection conducts periodic dietary analysis.

Which of the following do children with HIV often lack?

1. Vitamins 2. Sodium 3. Water 4. Calcium

Answer: 1 Rationale: 1. Vitamins can be especially lacking in the diets of infected children.

2. Sodium is not usually lacking in the diets of infected children.

3. Potassium is not usually lacking in the diets of infected children.

4. Water is not usually lacking in the diets of infected children.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 27-3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV) infection.

10. An adolescent has systemic lupus erythematosus (SLE). Which of the following actions by the teen indicates acceptance of the body changes that occur because of SLE? 1. Refuses to attend school.

2. Doesn’t want to attend any social functions.

3. Discusses the body changes with a peer.

4. Discusses the body changes with health care personnel only.

Answer: 3 Rationale: 1. Refusing to go to school indicates nonacceptance of the changes to body image.

2. Refusing to attend social functions indicates nonacceptance of the changes to body image.

3. Peer interaction is important to the teen. Being able to discuss the changes to his body with a peer indicates acceptance of the change in body image.

4. Discussing changes only with health care personnel does not indicate the teen has adjusted to the body image changes.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 27-4 Describe nursing management for the child with systemic lupus erythematosus or juvenile arthritis.

11. A school-age child with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which of the following would be the most appropriate for the nurse to recommend?

1. Softball 2. Football 3. Swimming 4. Basketball

Answer: 3 Rationale: 1. Softball could exacerbate joint discomfort.

2. Football could exacerbate joint discomfort.

3. Swimming helps to exercise all the extremities without putting undue stress on joints.

4. Basketball could exacerbate joint discomfort.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome: 27-4 Describe nursing management for the child with systemic lupus erythematosus or juvenile arthritis.

12. The nurse is caring for a child with rheumatoid arthritis. Which of the following is an appropriate non-pharmacological measure to reduce the joint pain associated this disease?1. Application of moist heat 2. Elevation of the extremity 3. Massage 4. Immobilization

Answer: 1 Rationale: 1. Moist heat can promote relief of pain and decrease joint stiffness.

2. Elevation of the extremity would not have an effect on reducing pain in rheumatoid arthritis.

3. Massage of extremities should be avoided because of potential risk for emboli.

4. Immobilization can lead to contractures. Range-of-motion to the involved joint should be maintained.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 27-4 Describe nursing management for the child with systemic lupus erythematosus or juvenile arthritis.

13. One of the nurse technicians is showing symptoms of latex sensitivity. Which of the following is the best action by the nurse?

1. Send the nurse technician to a department that does not use latex products.

2. Contact the employee health department in the facility and obtain latex-free products for the nurse technician.

3. Wait until Monday to report the problem to the supervisor of the unit.

4. Assign the nurse technician non–client care duties.

Answer: 2 Rationale: 1. Sending the nurse technician to a department that does not use latex products is not realistic because the nurse technician might experience exposure on another unit. (No hospital unit can be latex-free.) 2. When symptoms of sensitivity to latex occur on exposure, the employee health department of the facility should be contacted, and latex-free products should be supplied. 3. Waiting until Monday does not solve the problem. 4. Assigning the nurse technician non–client care duties would not be possible.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome: 27-5 Describe exposure prevention measures for the child with latex allergy.

14. A child with myelomeningocele has a latex allergy. Which product should not be used for a dressing change for this child?

1. 4 x 4 gauze 2. Transpore tape 3. Elastoplast 4. Duoderm

Answer: 3 Rationale: 1. 4 x 4 gauze is latex-free.

2. Transpore tape is latex-free.

3. Elastoplast is a product that frequently contains latex.

4. Duoderm is a latex-free product Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 27-5 Describe exposure prevention measures for the child with latex allergy.

15. Which of the following products should a nurse avoid when caring for a child with a latex allergy?

1. Oil-based hand creams 2. Vinyl gloves 3. Polyethylene products 4. Powder-free gloves

Answer: 1 Rationale: 1. Using oil-based hand creams and lotions before putting on latex gloves can break down the latex.

2. Vinyl gloves are an alternative for latex.

3. Polyethylene products can substitute for latex products.

4. Power can have high amounts of latex. Powder-free gloves are recommended.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 27-5 Describe exposure prevention measures for the child with latex allergy.

16. The nurse is caring for a child who experiences an anaphylactic shock reaction.

Which of the following positions would be the most appropriate in which to place this child?

1. Trendelenburg position 2. high Fowler’s

position

3.

reverse

Trendelenburg position 4. Flat, with legs slightly elevated

Answer: 4 Rationale: 1. The Trendelenburg position has the head of the bed elevated, and will not be effective to maintain a blood pressure when shock is occurring. It is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling.

2. The high Fowler’s position has the head of the bed elevated, and will not be effective to maintain a blood pressure when shock is occurring.

3. The reverse Trendelenburg position has the head of the bed elevated, and will not be effective to maintain a blood pressure when shock is occurring.

4. Flat, with legs slightly elevated, is the position that is used for a client experiencing shock. This allows for the blood pressure to be maintained during this critical time.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 27-6 Apply nursing interventions and prevention measures for the child experiencing a hypersensitivity reaction.

17. A child has been placed on an oral corticosteroid for a rash caused by graft-versushost disease. For which of the following should the nurse monitor this child?

1. Hyperglycemia 2. Renal toxicity 3. Hepatic toxicity 4. Seizures

Answer: 1 Rationale: 1. Hyperglycemia is a side effect of steroid therapy.

2. Renal toxicity is not a side effect associated with steroid therapy.

3. Hepatic toxicity is not a side effect associated with steroid therapy.

4. Seizures are not a side effect associated with steroid therapy.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 27-6 Apply nursing interventions and prevention measures for the child experiencing a hypersensitivity reaction.

18. A nurse has begun an infusion of intravenous immunogloblin (IVIG) to a child who has combined immunodeficiency disease. In which of the following situations should this infusion be stopped?

1. The child experiences a mild headache.

2. The child voids clear yellow urine.

3. The child develops severe shaking, chills, and fever.

4. The child complains of being “thirsty.”

Answer: 3 Rationale:

1. A mild headache is an adverse side effect of IVIG, but a severe reaction is not.

2. Voiding clear, yellow urine is a normal finding.

3. Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction.

4. Thirst is not an indication of a reaction.

Cognitive Level: Application.

Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 27-6 Apply nursing interventions and prevention measures for the child experiencing a hypersensitivity reaction.

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1. Vitamin K injections are given to newborn infants to: 1. Activate clotting factors.

2. Anticoagulate.

3. Increase fetal hemoglobin.

4. Assist in gas exchange Answer: 1 Rationale: 1. Levels of clotting factors are lower in infants, so vitamin K is given prophylactically to activate essential clotting factors.

2. Vitamin K is given to promote coagulation.

3. Vitamin K has no effect on fetal hemoglobin.

4. Clotting factors do not carry oxygen or carbon dioxide.

Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 28-1 Describe the function of red blood cells, white blood cells, and platelets.

2. Which of the following are functions of white blood cells? Select all that apply.

1. Phagocytosis 2. Aid in immunity 3. Clumping to decrease bleeding 4. Combat infection 5. Carrying oxygen Answer: 1, 2, 4 Rationale: 1. Phagocytosis is a function of neutrophils (white blood cells).

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2. Lymphocytes (white blood cells) are responsible for humoral and cellular immunity.

3. Platelets form hemostatic plugs to stop bleeding.

4. White blood cells are the mobile protective units in the body.

5. Hemoglobin in the red blood cells carries oxygen.

Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 28-1 Describe the function of red blood cells, white blood cells, and platelets.

3. The polycythemia present in infants and children can best be explained as the body’s response to: 1. Infection.

2. Oxygen need.

3. Bleeding.

4. Hypoglycemia.

Answer: 2 Rationale: 1. Infection can increase the need for oxygen but does not result in polycythemia.

2. When a child is hypoxic, the kidney produces erythropoietin, signaling the marrow to produce more red blood cells.

3. Bleeding is controlled by platelets, not red blood cells.

4. Hypoglycemia has no effect on red blood cell production.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 28-1 Describe the function of red blood cells, white blood cells, and platelets.

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4. The nurse is evaluating the activity tolerance of a 9-month-old with iron-deficiency anemia. Which of the following findings indicates that the child is tolerating activity?

1. Tachycardia 2. Decreased alertness 3. Respiratory rate less than 50 with activity 4. Muscle weakness

Answer: 3 Rationale: 1. Tachycardia, decreased alertness, and muscle weakness are all signs that irondeficiency anemia is not resolving and activity tolerance is not improving.

2. Tachycardia, decreased alertness, and muscle weakness are all signs that irondeficiency anemia is not resolving and activity tolerance is not improving.

3. Iron-deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is tolerating activity and that iron-deficiency anemia is resolving would be the child’s maintaining a respiratory rate of less than 50 (within a normal range for this age) during activity.

4. Tachycardia, decreased alertness, and muscle weakness are all signs that irondeficiency anemia is not resolving and activity tolerance is not improving.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

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5. Which of the following parental demonstrations indicates that they understand the nurse’s teaching with regard to prevention of iron-deficiency anemia?

1. The parents feed their infant with a formula that is not iron-fortified.

2. The parents start iron-fortified infant cereal at 4–6 months of age.

3. Cow’s milk is introduced into the child’s diet at 6 months of age.

4.

The child’s vitamin C consumption is limited after 1 year of age.

Answer: 2 Rationale: 1. The infant’s maternal iron stores are depleted by 6 months. Infants who are not breastfed should get iron-fortified formula.

2. Starting iron-fortified infant cereal at 4–6 months of age is recommended for prevention of iron deficiency in children.

3. Cow’s milk should not be introduced until 12 months of age.

4. Vitamin C should be started at 6–9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

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6. A child has been diagnosed with sickle-cell disease. The parents ask the nurse how their child got this disease. Which of the following is the best response to give the parents?

1. The mother and the father of the child have the sickle-cell trait.

2. The mother of the child has the trait, but the father doesn’t.

3. The father of the child has the trait, but the mother doesn’t.

4.

The mother of the child has sickle-cell disease, but the father doesn’t have the

disease or the trait.

Answer: 1 Rationale: 1. Sickle-cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have 25% chance of having this disease.

2. Both parents must have the trait for the child to have a 25% chance of having this disease.

3. Both parents must have the trait for the child to have a 25% chance of having this disease.

4. Both parents must have the trait for the child to have a 25% chance of having this disease.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment

Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the

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major disorders of red blood cells affecting the pediatric population.

7. A child with sickle-cell disease is being admitted with splenic sequestration crisis.

Which of the following rooms would be most appropriate to assign this child to?

1.

Semi-private room

2. Reverse-isolation room 3. Contact-isolation room 4.

Private room

Answer: 4 Rationale: 1. The child should not be exposed to other children with potentially infectious illnesses, so a semi-private room is not appropriate.

2. Reverse isolation is not necessary.

3. The child is not contagious, and contact isolation is not necessary.

4. Splenic sequestration can be life-threatening, and there is profound anemia. The child should not be placed in a room with any child who might have an infectious illness. A private room is appropriate for this child.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

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8. Which medication should the nurse expect to administer to a child admitted with sickle-cell pain?

1. Morphine sulfate (Duramorph) 2. Meperidine (Demerol) 3. Acetaminophen (Tylenol) 4.

Ibuprofen (Advil)

Answer: 1 Rationale: 1. The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA).

2. Meperidine is not used for pain control for clients with sickle-cell pain crisis, because it can cause seizures.

3. Acetaminophen or ibuprofen is used for mild pain, and would not be effective for the severe pain experienced by a child in sickle-cell pain crisis.

4. Acetaminophen or ibuprofen is used for mild pain, and would not be effective for the severe pain experienced by a child in sickle-cell pain crisis.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

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9. The nurse is teaching parents how to prevent a sickle-cell crisis in the child with sickle-cell disease. Which of the following are precipitating factors that could contribute to a sickle-cell crisis? Select all that apply.

1. Fever 2. Dehydration 3. Regular exercise 4. Altitude 5.

Increased fluid intake

Answer: 1, 2, 4 Rationale: 1. Fever, dehydration, and altitude are all precipitating factors contributing to a sicklecell crisis.

2. Fever, dehydration, and altitude are all precipitating factors contributing to a sicklecell crisis.

3. Regular exercise and increased fluid intake are recommended activities for a child with sickle-cell disease, and will not contribute to a sickle-cell crisis.

4. Fever, dehydration, and altitude are all precipitating factors contributing to a sicklecell crisis.

5. Regular exercise and increased fluid intake are recommended activities for a child with sickle-cell disease, and will not contribute to a sickle-cell crisis.

Cognitive Level: Analysis Client Need: Physiological integrity Nursing Process: Assessment

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Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

The nurse is administering packed red blood cells to a child with sickle-cell disease (SCD). The nurse knows that a transfusion reaction will most likely occur: 1. Six hours after the transfusion is given.

2. Within the first 20 minutes of administration of the transfusion.

3. At the end of the administration of the transfusion.

4.

Never; children with SCD do not have reactions.

Answer: 2 Rationale: 1. Transfusion reaction does not occur this long after the transfusion.

2. Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child the first 20 minutes of the transfusion.

3. Reactions generally occur at the onset or during the first 20 minutes of transfusion.

4. Anyone can have a transfusion reaction during any transfusion.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment

Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

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11. A child who has Beta-thalassemia is receiving numerous blood transfusions. The child is also receiving deforaxamine (Desferal) therapy. The parents ask how the deforaxamine will help their child. Which of the following is a deforaxamine action that the nurse should convey?

1. Prevents blood transfusion reactions.

2. Stimulates red blood cell production.

3. Provides vitamin supplementation.

Prevents iron overload.

4.

Answer: 4 Rationale: 1. Desferal does not prevent blood transfusion reactions.

2. Desferal does not stimulate red blood cell production.

3. Desferal does not provide vitamin supplementation.

4. Iron overload can be a side effect of a hypertransfusion therapy. Deforaxamine (Desferal) is an iron-chelating drug that binds excess iron so it can be excreted by the kidneys. It does not prevent blood transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 28.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

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12. A child is admitted to the hospital and diagnosed with aplastic anemia. The parents ask the nurse what aplastic anemia is. Which of the following would be the nurse’s best response? Aplastic anemia: 1. Is characterized by abnormally shaped red blood cells.

2. Causes a proliferation of white blood cells.

3. Is characterized by failure of the bone marrow to produce adequate numbers of cells.

4. Is a disorder that occurs following a viral illness.

Answer: 3 Rationale: 1. Cells are normally shaped, just in insufficient numbers.

2. All blood cells are affected.

3. In aplastic anemia, the bone marrow does not produce sufficient numbers of circulating blood cells.

4. There is no known association with viral illness.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 28-3 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

13. When caring for a child diagnosed with aplastic anemia, the nurse would educate the parents regarding which common symptoms?

1. Nausea and vomiting 2. Runny nose and cough 3. Fatigue and fever

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4. Cyanosis and bradycardia Answer: 3 Rationale: 1. Nausea and vomiting are not symptoms of aplastic anemia.

2. Aplastic anemia is not associated with upper respiratory infections.

3. Fatigue secondary to anemia and fever related to infection secondary to neutropenia are common symptoms.

4. The child would exhibit tachycardia rather than bradycardia, and there is no reason for cyanosis.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 28-3 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

14. A child has recently been diagnosed with aplastic anemia. Support for the family should include: 1. Referrals to support groups and Social Services.

2. Short-term support.

3. Genetic counseling.

4.

Nutrition counseling.

Answer: 1 Rationale: 1. Families require support in dealing with a child who has a life-threatening disease.

They should be referred to support groups for counseling, and, if indicated, to Social Services.

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2. The support will be long-term in nature, not short-term.

3. Aplastic anemia is not a genetically transmitted disease.

4. Nutrition counseling is not a priority, and might not be needed, with aplastic anemia.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Planning Learning Outcome 28.3 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

15. A child with hemophilia comes to the Emergency Department following an automobile accident. The child presents with multiple injuries. When prioritizing care for the child, the nurse would be most concerned with which of the following injuries?

1. Radial fracture 2. Abdominal abrasions 3. Dislocated shoulder 4. Occipital hematoma

Answer: 4 Rationale: 1. Although at risk for bleeding, this would not take priority over a head injury.

2. Although at risk for bleeding, this would not take priority over a head injury.

3. A dislocation is not at high risk for bleeding or tissue ischemia.

4. A potential intracranial bleed would receive highest priority because of the danger of increased intracranial pressure and potential neurologic damage.

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Learning Outcome 28-4 Discuss the pathophysiology and clinical manifestations of major bleeding disorders affecting the pediatric population.

16. A school-age child with hemophilia falls on the playground and goes to the nurse’s office with superficial bleeding above the knee. The nurse should: 1. Apply a warm, moist pack to the area.

2. Perform some passive range-of-motion to the affected leg.

3. Apply pressure to the area for at least 15 minutes.

4.

Keep the affected extremity in a dependent position.

Answer: 3 Rationale: 1. Heat would increase the bleeding by dilating the superficial blood vessels.

2. The extremity should be immobilized to prevent further bleeding; passive range-ofmotion could cause further bleeding at the site.

3. If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes, and ice should be applied.

4. The extremity should be elevated, if possible, to prevent swelling at the site.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 28.4 Discuss the pathophysiology and clinical manifestations of major bleeding disorders affecting the pediatric population.

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17. A child with hemophilia plans on participating in a bicycling club. Which of the following recommendations should the nurse give to the child?

1. Consider a swim club instead of the bicycling club.

2. Wear kneepads, elbow pads, and a helmet while bicycling.

3. Participate only in the social activities of the club.

4.

Do not join the club.

Answer: 2 Rationale: 1. Biking is an acceptable sport as long as protective equipment is worn, and the child should be encouraged to make choices when possible.

2. Children with hemophilia should be encouraged to participate in non-contact sports activities. Bicycling is an excellent option, and is recommended, along with swimming.

However, the child should always use kneepads, elbow pads, and a helmet when participating in any physical sport.

3. Participating only in the social aspects of the club would not encourage physical activity.

4. Discouraging a child from joining a club would not foster growth and development.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Learning Outcome 28.4 Discuss the pathophysiology and clinical manifestations of major bleeding disorders affecting the pediatric population.

18. The nurse is caring for a child with disseminated intravascular coagulation (DIC).

Which of the following would be a priority nursing intervention for this child?

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1. Frequent ambulation 2. Maintenance of skin integrity 3. Monitoring of fluid restriction 4.

Preparation for radiograph procedures

Answer: 2 Rationale: 1. Ambulation places stress on joints, and can promote bleeding. The child with DIC should be placed on bedrest.

2. Impairment of skin integrity can lead to bleeding in DIC, so maintenance of skin integrity is a priority when caring for a child with this.

3. Fluids need to be monitored, but will not be restricted.

4. DIC is not diagnosed with radiograph examination but by serum lab studies.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 28.4 Discuss the pathophysiology and clinical manifestations of major bleeding disorders affecting the pediatric population.

19. Which of the following is a priority nursing diagnosis for the child with idiopathic thrombocytopenic purpura (ITP)?

1. Risk for injury 2. Ineffective breathing pattern 3. Nausea 4.

Fluid-volume deficit

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Rationale: 1. ITP is the most common bleeding disorder in children, so risk for injury and subsequent bleeding is the priority nursing diagnosis.

2. Although—in an advanced state—ITP can impact breathing, it does not usually cause ineffective breathing patterns.

3. Nausea is not a symptom of ITP. 4. Fluid-volume deficits are not likely to occur with ITP. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis

Learning Outcome 28.4 Discuss the pathophysiology and clinical manifestations of major bleeding disorders affecting the pediatric population.

20. A child with meningococcemia is being admitted to the pediatric intensive care unit.

This child should be placed in which type of room?

1. Semiprivate room 2. Private room, but not in isolation 3. Private room, in protective isolation 4.

Private room, in respiratory isolation

Answer: 4 Rationale: 1. Meningococcemia is very contagious, and other children should not be exposed to a child who has been diagnosed with it.

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2. A patient with meningococcemia is contagious, and must be placed in isolation.

3. The child does not need to be protected from others, and does not need protective isolation.

4. Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 28.4 Discuss the pathophysiology and clinical manifestations of major bleeding disorders affecting the pediatric population.

21. During discharge teaching to parents of a child hospitalized with sickle-cell crisis, the nurse should emphasize which of the following as a priority home care intervention?

1. Encouraging adequate hydration 2. Promotion of a diet high in protein 3. Restriction of activities 4. Rapid weaning of pain medications

Answer: 1 Rationale: 1. Adequate hydration will help prevent further sequestration and crisis.

2. A high-protein diet is not necessary; a well balanced diet should be promoted.

3. Normal activities are not restricted.

4. Rapid weaning is not necessary; reduction of pain medication should proceed at a rate dictated by the child’s pain.

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Nursing Process: Intervention Learning Outcome 28-5 Describe nursing management and collaborative care of a child with a hematologic disorder.

22. Which complication(s) should the nurse observe for during administration of Factor VIII to a child with hemophilia?

1. Congestive heart failure 2. Fever and chills 3. Nausea and vomiting 4. Fat emboli Answer: 2 Rationale: 1. Factor VIII is not a large volume, and the child is not at risk for CHF. 2. Fever and chills are common symptoms of transfusion reactions, which can occur with the administration of any blood product. Factor VIII is a blood product.

3. Nausea and vomiting are not usually associated with a transfusion reaction.

4. Although the nurse can watch for the symptoms of emboli, the nurse cannot directly observe for fat emboli formation.

Cognitive Level: Application Client Need: Physiologic Integrity Nursing Process: Assessment Learning Outcome 28-5 Describe nursing management and collaborative care of a child with a hematologic disorder.

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23. A nurse is planning to provide education for a family who has a child with sickle-cell anemia. For the prevention of a sickle-cell crisis, the nurse should teach the family the importance of avoiding: 1. Overhydration.

2. Midrange altitudes.

3. Weight loss without dehydration.

4. Respiratory infection and dehydration.

Answer: 4 Rationale: 1. Hydration should be encouraged; risk of overhydration is minimal.

2. High altitudes with lower oxygen concentrations pose a risk; mid-altitude is not a risk factor.

3. Weight loss is acceptable as long as hydration is maintained.

4. The child with sickle-cell disease is at risk for infection, and dehydration can precipitate crisis.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Intervention Learning Outcome 28-5 Describe nursing management and collaborative care of a child with a hematologic disorder.

24. Which of the following are major risks during the post-transplant phase of hematopoietic stem cell transplantation (HSCT)? Select all that apply.

1. Infection 2. Fluid volume overload 3. Pancytopenia 4. Thrombosis

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5. Bleeding Answer: 1, 3, 5 Rationale: 1. Suppression of white blood cells increases the patient’s risk for infection.

2. There is no increased risk of excess fluid; the patient is at greater risk for dehydration.

3. It takes 2–4 weeks for the bone marrow to begin producing cells; the patient will show evidence of suppression until that time.

4. There is no increased risk for thrombosis.

5. Suppression of platelets increases the risk for bleeding.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Assessment Learning Outcome 28-6 Discuss nursing implications for a child receiving hematopoietic stem cell transplantation (HSCT).

25. A child is being admitted for mild neutropenia and a severe oral monilial infection post–hematopoietic stem cell transplantation (HSCT). To which of the following rooms should the nurse assign this child?

1. Semi-private room 2. Private room with negative pressure 3. Private room 4. Semi-private room with protective isolation Answer: 3 Rationale: 1. Risk of infection would prohibit use of a semi-private room.

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2. A negative-pressure room is not indicated for a mild neutropenia.

3. A private room to minimize risk of infection is appropriate. No further precautions are necessary.

4. A semi-private room and protective isolation are not appropriate for this patient.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 28-6 Discuss nursing implications for a child receiving hematopoietic stem cell transplantation (HSCT).

26. A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which of the following concepts are important for the nurse to include in discharge education? Select all that apply.

1. Keeping the child on a high-calcium diet 2. Returning the child to school within six weeks 3. Practicing good handwashing 4. Avoiding influenza vaccinations 5.

Avoiding live plants and fresh vegetables

Answer: 1, 3, 5 Rationale: 1. The child should be placed on calcium supplements to reduce the risk of osteopenia.

Handwashing is essential to prevent the spread of infection. Live plants and fresh vegetables can carry bacteria; they should be avoided to decrease the risk of infection.

2. The child can’t return to school for 6–12 months after an HSCT. In-hospital or inhome schooling is required. The child and the family should be encouraged to get a yearly influenza vaccination.

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3. The child should be placed on calcium supplements to reduce the risk of osteopenia.

Handwashing is essential to prevent the spread of infection. Live plants and fresh vegetables can carry bacteria; they should be avoided to decrease the risk of infection.

4. The child can’t return to school for 6–12 months after an HSCT. In-hospital or inhome schooling is required. The child and the family should be encouraged to get a yearly influenza vaccination.

5. The child should be placed on calcium supplements to reduce the risk of osteopenia.

Handwashing is essential to prevent the spread of infection. Live plants and fresh vegetables can carry bacteria; they should be avoided to decrease the risk of infection.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 28.6 Discuss nursing implications for a child receiving hematopoietic stem cell transplantation (HSCT).

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1. A child has been diagnosed with a Wilms’ tumor, and is being treated with chemotherapy. Prior to administering the chemotherapy, the nurse will determine if this child has any infection-fighting capability by monitoring the: 1. Hemoglobin.

2. Red blood cell count.

3. Absolute neutrophil count (ANC).

4.

Platelets.

Answer: 3 Rationale: 1. Hemoglobin indicates oxygen-carrying capacity, not immune response.

2. Red blood cell count has no correlation with immune function.

3. The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body’s infection-fighting capability.

4. Platelets are associated with clotting, not immune function.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 29.1 Describe the incidence, known etiologies, and clinical manifestations of cancer.

2. Manifestations of cancer in the pediatric patient vary by type and location, but include which of the following general manifestations? Select all that apply.

1. Infection 2. Pain

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3. Weight gain 4. Cachexia 5. Neurologic symptoms 6. Polycythemia

Answer: 1, 2, 4, 5 Rationale: 1. Infection related to decreased immune function is common.

2. Pain results from neoplasm’s directly or indirectly affecting nerve receptors.

3. Weight gain is incorrect; children with cancer are generally anorexic, have nausea and vomiting, and have early satiety.

4. Cachexia occurs secondarily to anorexia and nausea and vomiting.

5. Neurologic symptoms can occur from impingement on the brain or nervous system.

6. Anemia occurs rather than polycythemia.

Cognitive Level: Comprehension Client Need: Physiological Assessment Nursing Process: Assessment Learning Outcome 29.1 Describe the incidence, known etiologies, and clinical manifestations of cancer.

3. The parent of a child newly diagnosed with cancer verbalizes regret to the nurse for not seeking earlier medical attention for the child’s symptoms. Which of the following responses would be most therapeutic?

1. “Many types of cancer are difficult to diagnose, and might not show early symptoms.”

2. “You may feel guilty, but you should not blame yourself.”

3. “Most cancers can be treated easily.”

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4. “Early diagnosis is not significant in the diagnosis and management of cancer.”

Answer: 1 Rationale: 1. Many cancers do not present significant findings until late, and can progress rapidly.

Giving such information is a communication tool.

2. This is not a therapeutic response. It is not appropriate for the nurse to tell the family how they should feel.

3. This answer is not accurate, as cancer is generally prolonged, and difficult for both child and family.

4. Outcomes for many cancers are improved with early diagnosis.

Cognitive Level: Analysis Client Need: Physiological Integrity: Adaptation Nursing Process: Implementation Learning Outcome 29.1 Describe the incidence, known etiologies, and clinical manifestations of cancer.

4. A child has cancer, and has been treated with chemotherapy. The latest lab value indicates that the white blood cell count is very low. The nurse would expect to administer: 1. Filgrastim (Neupogen).

2. Ondansetron (Zofran).

3. Oprelvekin (Neumega).

4.

Epoetin alfa (Epogen).

Answer: 1

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Rationale: 1. Filgrastim (Neupogen) increases production of neutrophils by the bone marrow.

2. Ondansetron (Zofran) is an antiemetic.

3. Oprelvekin (Neumega) increases platelets.

4. Epoetin alfa (human recombinant erythropoietin) stimulates red blood cell (RBC) production.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 29.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

5. The nurse is monitoring the urine specific gravity and pH on a child receiving chemotherapy. The nurse will try to maintain the urine values at: 1. Specific gravity 1.030; pH 6.

2. Specific gravity 1.030; pH 7.5.

3. Specific gravity 1.005; pH 6.

4.

Specific gravity 1.005; pH 7.5.

Answer: 4 Rationale:

1. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis.

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2. A specific gravity higher than 1.010 can mean fluid intake is not high enough.

3. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis.

4. Because the breakdown of malignant cells releases intracellular components into the blood, and electrolyte imbalance causes metabolic acidosis, the patient should remain well hydrated, with the urine specific gravity at less than 1.010 and the pH at 7–7.5.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 29.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

6. The antiemetic drug ondansetron (Zofran) is being administered to a child receiving chemotherapy. It should be administered: 1. Only if the child experiences nausea.

2. After the chemotherapy has been administered.

3. Before chemotherapy administration, as a prophylactic measure.

4.

Never; this antiemetic is not effective for controlling nausea and vomiting

associated with chemotherapy.

Answer: 3 Rationale: 1. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea.

2. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea.

3. The antiemetic ondansetron (Zofran) should be administered before

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chemotherapy, and every four hours during the administration of chemotherapy, as a prophylactic measure.

4. It is the drug of choice for controlling nausea caused by chemotherapy agents.

Cognitive Level: Application Client Need: Physiological Integrity Learning Process: Planning Learning Outcome 29.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

7. A child has thrombocytopenia secondary to chemotherapy treatments. The nurse should not: 1. Administer intramuscular injections (IM).

2. Perform oral hygiene.

3. Monitor intake and output.

4.

Use palpation as a component of assessment.

Answer: 1 Rationale: 1. When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections, because of the risk of bleeding.

2. Oral hygiene care should be done with a soft toothbrush.

3. Intake and output should be monitored for any abnormalities.

4. Gentle palpation should still be included in physical assessments unless a Wilms’ tumor has been diagnosed or is suspected.

Cognitive Level: Application Client Need: Physiological Integrity

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Nursing Process: Implementation Learning Outcome 29.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

8. The child is receiving chemotherapy for acute lymphocytic leukemia. The nurse recognizes that a potential oncological emergency for this child would be tumor lysis syndrome. For which of the following symptoms should the nurse monitor this child?

1. Thrombocytopenia and leukocytosis 2. Oliguria and altered levels of consciousness 3. Respiratory distress and cyanosis 4.

Upper-extremity edema and neck vein distension

Answer: 2 Rationale: 1. Thrombocytopenia and leukocytosis occur with a hematological emergency.

2. Tumor lysis causes a metabolic emergency. Because of electrolyte imbalance, the signs can be oliguria and altered levels of consciousness. Thrombocytopenia and leukocytosis occur with a hematological emergency.

3. Respiratory distress and cyanosis would be associated with space-occupying lesions or a hematologic emergency.

4. Upper-extremity edema and neck vein distension are not priority concerns for this client.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment

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Learning Outcome 29.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

9. A child undergoing chemotherapeutic treatment for cancer is being admitted to the hospital for fever and possible sepsis. Cultures, antibiotics, and acetaminophen (Tylenol) along with bedrest have been ordered for this child.

Place the following steps in order from first to last.

1. Administer the antibiotics.

2. Administer IVFs as ordered.

3. Obtain ordered cultures.

4. Ensure the child has bedrest.

Answer: 3,1,2,4 Explanation: Obtain the cultures first, because management of infections is critical, and since a child on chemotherapy has lowered immune status, unusual agents can be identified. Cultures can help identify the causative agents before treatment is started. Give the antibiotics next, as an infection can seriously impact the child who is receiving chemotherapy. Provide IVF after the higher-risk need of providing antibiotics had been met, unless the child is in shock, in which case IVF therapy would take precedence. Provide comfort followed by bedrest to allow the child to rest, once higherpriority needs have been met.

Cognitive: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 29.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

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10. A 12-year-old undergoing chemotherapy for leukemia presents to the Emergency Department with blood in his urine. Which of the following interventions would the nurse perform first?

1. Explain to the child that this is a common side effect of chemotherapy.

2. Calculate a 24-hour intake and output.

3. Request an order for IV fluids.

4. Report this finding to the physician immediately.

Answer: 4 Rationale: 1. Blood in the urine is not an acceptable side effect of chemotherapy.

2. Calculating I/O is a routine nursing intervention, and is not specific to treatment for blood in the urine.

3. The child should have been adequately hydrated prior to the most recent chemotherapy. Unless nausea and vomiting are present, oral fluids should be encouraged before the administration of IVF. 4. This could signify tumor lysis syndrome, and is a potential emergency that should be reported quickly.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 29.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

11. A 24-hour urine collection has been ordered at 1030, for a child receiving

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vanillylmandelic acid (VMA). Urine collection should begin: 1. At 0700.

2. With the child’s next void.

3. At bedtime.

4.

When the order is noted.

Answer: 2 Rationale: 1. It would not be an accurate collection of 24 hours of urine if the collection began at 0700.

2. A 24-hour urine collection is started after the child’s next void.

3. It would not be an accurate collection of 24 hours of urine if the collection began at bedtime.

4. It would not be an accurate collection of 24 hours of urine if it began when the order was noted.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 29.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

12. A child has been diagnosed with a Wilms’ tumor; preoperative nursing care would involve: 1. Careful bathing and handling.

2. Monitoring of behavioral status.

3. Maintenance of strict isolation.

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Administration of packed red blood cells.

Answer: 1 Rationale: 1. Careful bathing and handling are an important nursing consideration to prevent pressure on the tumor.

2. The child’s behavior will not be affected with a Wilms’ tumor.

3. The tumor does not cause excessive lowering of WBCs, so strict isolation is not necessary.

4. The tumor does not cause excessive lowering of RBCs, so administration of packed red blood cells is not usually a nursing intervention.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 29.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

13. An adolescent is receiving methotrexate chemotherapy after undergoing limb-salvage surgery for osteogenic sarcoma. The nurse knows the teen understands what to expect for the schedule of administration for leucovorin therapy if the teen says: 1. “I’m glad I only need one dose of the leucovorin.”

2. “I don’t have any pain, so I won’t need to take the leucovorin this time.”

3. “I know I will be taking the leucovorin every six hours for about the next three days.”

4.

“I don’t have any nausea, so I won’t need the leucovorin.”

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1. One dose is not the recommended therapy.

2. Leucovorin is not administered for pain.

3. Leucovorin (citrovorum factor) is a form of folic acid that helps to protect normal cells from the destructive action of methotrexate. It is started within 24 hours of methotrexate administration, and is given along with hydration therapy. Usual administration is every six hours times 72 hours, or until serum methotrexate is at the desired level.

4. Leucovorin is administered for nausea.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 29.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

14. A child has recently been diagnosed with leukemia. The child’s sibling is expressing feelings of anger and guilt. This reaction by the sibling is: 1. Abnormal; the sibling should be referred to a psychologist.

2. Unusual; the illness doesn’t affect the sibling.

3. Unexpected; the cancer is easily treated.

4.

Normal; the sibling is affected, too, and anger and guilt are expected feelings.

Answer: 4 Rationale: 1. Siblings are generally affected to some degree, but this a normal reaction.

2. A diagnosis of cancer affects the entire family; siblings will be affected to some degree.

3. Cancer is not easily treated, and will affect the entire family.

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