Child Health Nursing, 3E Jane W Ball Test Bank

Child Health Nursing, 3E

By Jane W. Ball

Email: richard@qwconsultancy.com

Ball, Child Health Nursing, 3/E Chapter 1 Question 1 Question 1 Type: MCSA 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 a six-year-old with diversional activity deficit related to placement in isolation.

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

3. Diagnose an eight-year-old with acute otitis media and prescribe an antibiotic.

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

Correct Answer: 3 Rationale 1: Nursing diagnoses are a responsibility of the nurse in an acute care unit.

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

Rationale 3: 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.

Rationale 4: Providing information about support groups is within the expectations of the nurse in an acute care unit.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 Question 2 Type: MCSA Despite the availability of Children's Health Insurance Programs (CHIP), many eligible children are not enrolled.

The nursing intervention that can best help eligible children to become enrolled is: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Educating the family about the need for keeping regular well-child visit appointments.

2. Assessing details of the family's income and expenditures.

3. Limiting costly, unnecessary duplication of services through case management.

4. Advocating for the child by encouraging the family to investigate CHIP eligibility.

Correct Answer: 4 Rationale 1: While it is the nurse's responsibility to educate the family, this intervention is not what will best help eligible children to become enrolled.

Rationale 2: Financial assessment is more commonly the function of a social worker.

Rationale 3: The case management activity mentioned will not provide a source of funding.

Rationale 4: In the role of an advocate, a nurse advances the interests of the child by suggesting that the family investigate CHIP eligibility.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 Question 3 Type: MCSA A nurse is examining different nursing roles. Which best illustrates an advanced practice nursing role?

1. A clinical nurse specialist with whom other nurses consult for her expertise in caring for high-risk children 2. A clinical nurse specialist working as a staff nurse on a medical-surgical pediatric unit 3. A registered nurse who is the circulating nurse in surgery 4. A registered nurse who is the manager of a large pediatric unit Correct Answer: 1 Rationale 1: 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.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: 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.

Rationale 3: A registered nurse 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.

Rationale 4: A registered nurse who is the manager of a large pediatric unit is defined as a professional nurse and has graduated from an accredited program in nursing and completed the licensure examination.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-1 Question 4 Type: MCSA The role of the registered nurse as a nurse educator is to: 1. Provide primary care for healthy children.

2. Assist the family in making informed decisions by providing information about the pros and cons of the treatment plan.

3. Assist the primary care nurse with procedures requiring advanced practice skills.

4. Communicate with the hospitalized school-aged child’s classroom teacher to assist the child in achieving classroom goals.

Correct Answer: 2 Rationale 1: The nurse educator does not provide primary care for healthy children.

Rationale 2: The educator works with the family toward the goal of making informed choices through education and explanation.

Rationale 3: The nurse educator does not assist with procedures requiring advance practice skills.

Rationale 4: The nurse educator is concerned with teaching the child and parents health care practices related to the child’s condition.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 Question 5 Type: MCSA 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 2020 2. National clinical practice guidelines 3. Child mortality statistics 4. Critical clinical pathways Correct Answer: 4 Rationale 1: Healthy People 2020 contains objectives set by the U.S. government to improve the health and reduce the incidence of death in the twenty-first century.

Rationale 2: National clinical practice guidelines promote uniformity in care for specific disease conditions by suggesting expected outcomes from specific interventions.

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

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-2 Question 6 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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. Between six and eight months old.

2. Of a Native American family.

3. Of a non-Hispanic black family.

4. Younger than three weeks old.

Correct Answer: 4 Rationale 1: About two-thirds of infant deaths occur much earlier—in the first 28 days of life.

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

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

Rationale 4: Almost two-thirds of all infant deaths occur during the first 28 days after birth.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-3 Question 7 Type: MCSA 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. Unintentional injury."

2. Infectious disease."

3. Congenital anomalies."

4. Cancer."

Correct Answer: 1 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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

Rationale 2: Infectious disease is not the cause of most deaths in children.

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

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1-3 Question 8 Type: MCSA With regard to child mortality statistics, which nursing intervention would be most effective in decreasing mortality from unintentional injury?

1. Teaching children about dangers of contact sports 2. Encouraging parents to obtain genetic counseling 3. Educating parents about the benefits of immunizations 4. Teaching parents about proper use of vehicle restraint seats Correct Answer: 4 Rationale 1: Teaching about the dangers of contact sports will not decrease mortality from unintentional injuries, such as burns, motor vehicle crashes, and suffocation.

Rationale 2: Obtaining genetic counseling will not decrease mortality from unintentional injuries.

Rationale 3: Since the most common cause of mortality in children is unintentional injury, educating about immunizations will not be most effective.

Rationale 4: 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.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-3 Question 9 Type: MCSA With regard to infant mortality statistics, which nursing intervention would be most effective in decreasing postneonatal mortality?

1. Teaching parents about "baby-proofing" their home 2. Educating parents on acceptable feeding techniques 3. Providing support for first-time mothers 4. Educating parents on the importance of positioning the baby on his back whenever sleeping Correct Answer: 4 Rationale 1: Baby-proofing homes will not decrease post-neonatal mortality.

Rationale 2: Teaching acceptable feeding techniques is not the most effective intervention to decrease postneonatal mortality.

Rationale 3: Providing support for first-time mothers will not decrease post-neonatal mortality.

Rationale 4: Sudden infant death syndrome accounts for nearly 8% of deaths to infants and usually occurs during the post-neonatal 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-3 Question 10 Type: MCSA Despite the availability of the Children's Health Insurance Program (CHIP), families often fail to obtain coverage for eligible children because: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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

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

3. They do not know their child is eligible.

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

Correct Answer: 3 Rationale 1: Most families do value insurance coverage, so this is not the reason for failing to obtain SCHIP coverage.

Rationale 2: Families have adequate time to complete the enrollment process, but some do not believe they will qualify and therefore do not try to enroll.

Rationale 3: Despite availability of CHIP, many eligible children are not enrolled. Reasons families have not enrolled include not being aware that their child is eligible, viewing the enrollment requirements and income verification tests as barriers, and the monthly premium or co-payment for healthcare visits that are required in some states.

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-3 Question 11 Type: MCSA 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. Social worker.

3. Unit secretary.

4. Physician.

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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

Rationale 2: A social worker is not responsible for obtaining informed consent for an invasive procedure.

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

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-4 Question 12 Type: MCSA 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 babysitter with written proxy consent.

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

4. The cohabitating unmarried boyfriend of the child's mother.

Correct Answer: 2 Rationale 1: State laws vary. In the case of divorced parents, the parent with custody may be the only parent allowed to give informed consent.

Rationale 2: A parent may grant proxy consent in writing to another adult so that children are not denied necessary health care.

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

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: Residence in the same household with a child does not authorize an adult to sign consent for treatment.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-4 Question 13 Type: MCSA 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 a mature minor.

2. That of an emancipated minor.

3. That of assent.

4. None.

Correct Answer: 3 Rationale 1: 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.

Rationale 2: An emancipated minor is a self-supporting adolescent who is not subject to the control of a parent or guardian.

Rationale 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- to 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.

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 1-4 Question 14 Type: MCSA All of the following adolescents are in the emergency room for treatment. Which adolescent would be an emancipated minor?

1. The 15-year-old adolescent who disagrees with the parents in regard to the medical plan of care 2. The 14-year-old adolescent who understands the risks and benefits of treatment 3. The 17-year-old adolescent who is self-supporting and maintains her own apartment 4. The 16-year-old adolescent who ran away from home and is living with a friend Correct Answer: 3 Rationale 1: 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.

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

Rationale 3: 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.

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

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-4 Question 15 Type: MCMA 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?

Standard Text: Select all that apply.

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1. The 13-year-old client beginning participation in a research program for ADHD treatments 2. The precocious four-year-old starting as a cystic fibrosis research study participant 3. The 10-year-old starting in an investigative study for clients with precocious puberty 4. The seven-year-old leukemia client electing to receive a newly developed medication being researched Correct Answer: 1,3,4 Rationale 1: Federal guidelines mandate that research participants seven years old and older must receive developmentally appropriate information about healthcare procedures and treatments and give assent.

Rationale 2: A four-year-old is not old enough to understand any of the benefits and risks of the research trial and is not required to assent.

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

Rationale 4: Federal guidelines mandate that research participants seven years old and older must receive developmentally appropriate information about health care procedures and treatments and give assent.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-5 Question 16 Type: MCSA 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. "Feb. '05 Portacath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globulins hung and infusing at 30 ml/hr. Child smiling and playful throughout the procedure. P. Potter, RN" Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. "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" Correct Answer: 2 Rationale 1: While the description of the procedure is appropriate, this documentation does not include the date the note was written.

Rationale 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.

Rationale 3: This note does not specify the exact date and time at which the portacath was accessed. It also does not include the size of the Huber needle that was used.

Rationale 4: This option appropriately describes the procedure but neglects to include the date and how the client tolerated it.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-5 Question 17 Type: MCSA The pediatric nurse's best defense against an accusation of malpractice or negligence is that the nurse: 1. Is a nurse practitioner or clinical nurse specialist.

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

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

4. Followed the physician's written orders.

Correct Answer: 2 Rationale 1: 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.

Rationale 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.

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Rationale 3: Acting on the advice of the nurse manager is not enough to defend the nurse from accusations because the advice could be wrong or unethical.

Rationale 4: Following the physician's written orders is not enough to defend the nurse from accusations because the orders could be wrong or unethical.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-5 Question 18 Type: MCSA Following a traumatic birth, an infant is admitted to the neonatal intensive care unit. When the grandparents arrive at the hospital, they question the nurse caring for the baby about its condition and plan of care. The nurse who provides this information without permission from the parents would be committing: 1. Negligence 2. A breach of privacy 3. Malpractice 4. A breach of ethics Correct Answer: 2 Rationale 1: Negligence occurs when the nurse does something or fails to do something that a reasonably prudent nurse would not do or would not have done Rationale 2: 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 by other family members).

Rationale 3: A nurse charged with malpractice may face a lawsuit for engaging in nursing practice that caused harm to a patient.

Rationale 4: Ethics is a system of moral principles that guides nursing behavior. This situation does not describe an ethical issue.

Global Rationale:

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Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-5 Question 19 Type: MCSA While changing the diaper on a newborn in the presence of the mother, the nurse notes a belly binder wrapped around the umbilical cord. When questioned, the mother states this is the way the umbilical area is cared for in her culture. The nurse should: 1. Accept this practice as a cultural variation and allow the mother to care for the umbilicus.

2. Explain to the mother the risks associated with belly binders and encourage her to remove it.

3. Remove the belly binder and discard it.

4. Replace the belly binder with a coin as a safer cultural practice.

Correct Answer: 2 Rationale 1: A belly binder prevents the cord from drying and may promote infection in the area. Cultural practices that are harmful should be discouraged through education of those involved.

Rationale 2: In this case, the belly binder is a cultural practice. While not accepting the practice as safe, the nurse recognizes the practice as a cultural variation and will work with the mother to provide for the needs of her infant.

Rationale 3: While the use of a belly binder varies from traditional American practice, the nurse should avoid offending the family and creating a barrier to accepted medical practice.

Rationale 4: This response does not show cultural acceptance and may negatively impact the therapeutic relationship.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2 Question 20 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The nursing supervisor is observing the staff on the pediatric unit. Which nurse is providing family-centered care?

1. The nurse who delays morning care until after the family has visited the child 2. The nurse who suggests the mother take a break and get breakfast while the nurse changes the child’s dressings 3. While admitting a new client, the nurse explains the visitation rules of the unit to the parents and grandparents.

4. During discharge planning, the nurse recognizes the mother is unable to perform wound care on the client, so the nurse works with the family to determine which family member will be available to meet this child’s health care needs.

Correct Answer: 4 Rationale 1: This observation does not involve the nurse partnering with the family to meet the health care needs of the child.

Rationale 2: While encouraging the mother to maintain her own health, this observation does not promote nursefamily interaction to improve the health of the child.

Rationale 3: There is no evidence of family-centered care in this interaction.

Rationale 4: Assisting the family in planning for the health care needs of the child is an example of familycentered care. The nurse accepts the limitations of the mother while problem solving with the family to find a solution.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-4 Question 21 Type: MCMA A registered nurse has been asked to join the ethics committee of the hospital. In considering this appointment, the nurse would recognize that the committee might be considering ethical situations including: Standard Text: Select all that apply.

1. Issuance of a “Do Not Resuscitate” (allow natural death) order on a child who has been determined brain dead against the wishes of the parents.

2. Determining if a minor child who disagrees with the parents about the treatment plan can make an informed decision.

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3. Determining if a non-salvageable newborn can be used as an organ donor.

4. Investigating a medication error.

5. Consulting and intervening when parents are not in agreement on decisions of health care for their child.

Correct Answer: 1,3 Rationale 1: Ethical issues arise when the health care team must make decisions regarding potential outcome for the child and the beneficence of treatment.

Rationale 2: Informed decisions and the rights of the individual are legal issues, not ethical issues.

Rationale 3: Issues of organ donations and waiting lists for organs involve ethical issues that might be presented to the hospital ethics committee.

Rationale 4: Medication errors do not involve ethical issues but are system failures that need to be investigated.

Rationale 5: Staff nurses may work with parents in conflict resolution; it is not a function of an ethics committee.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-5 Question 22 Type: MCSA The rationale for nurses utilizing nursing intervention classifications (NICs) when developing a nursing care plan for a child on the unit is to: 1. Improve communication among nurses working with the child.

2. Assist medical records in documenting care provided for insurance purposes.

3. Aid the nursing supervisor in evaluating the nursing staff.

4. Coordinate medical orders with nursing orders.

Correct Answer: 1 Rationale 1: Standardizing the language assists each individual providing care to be consistent in the health care approach.

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Rationale 2: The purpose of the nursing care plan is to improve care provided to the child and is not related directly to insurance.

Rationale 3: The nursing care plan is a communication tool for all health care members caring for the child and is not related to nursing supervision.

Rationale 4: While the nursing care plan includes dependent and independent orders, this is not the purpose of standardized NICs. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-2 Question 23 Type: MCSA A 14-month-old child is admitted to the hospital. During the admission process, the nurse determines that the child and family are visiting this country from a foreign country. The nurse is unaware of the cultural traditions and values of that country. How can the nurse best provide culturally competent health care?

1. Read about that country on the internet.

2. Ask the family members how care would be provided in their own country.

3. Ask a nurse who has visited the child’s home country about life in that country.

4. Ask a coworker who comes from the same region about customs and cultures in their country.

Correct Answer: 2 Rationale 1: While this may provide some information about culture, this is not the best choice for this particular child and family.

Rationale 2: This response provides accurate information about this family’s beliefs and culture.

Rationale 3: This choice provides an outsider’s view of the country and is not the best response.

Rationale 4: While this may be helpful in seeing the full picture, the family is the most direct and complete source of information.

Global Rationale:

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Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 Question 24 Type: MCSA While working on the pediatric unit, the nurse recognizes a neighbor whose child has been admitted to the hospital pediatric intensive care. Out of curiosity, the nurse visits the PICU and reviews the child’s chart for information about the child’s diagnosis. This nurse: 1. Has violated HIPAA laws.

2. Was working within the legal limitations of his/her job.

3. Was not guilty of violating HIPAA laws unless the nurse shares the information with someone outside the hospital.

4. Was working as a member of the health care team to provide family-centered nursing.

Correct Answer: 1 Rationale 1: Because the nurse was not involved in the child’s care, the nurse had no right to review the chart and violated the family’s right to privacy by reviewing the chart.

Rationale 2: This nurse was not involved in the child’s care and had no legal right to the information.

Rationale 3: The nurse had no legal right to the information even if the information was not shared with others.

Rationale 4: Although the nurse was a member of the health care team, this nurse was not on the team assigned to this patient. It is a HIPAA violation.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-6

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Ball, Child Health Nursing, 3/E Chapter 2 Question 1 Type: MCSA A seven-year-old client tells you, "Grandpa, Mommy, Daddy, and my brother live at my house." The nurse identifies this family type as a(n): 1. Extended family.

2. Traditional nuclear family.

3. Binuclear family.

4. Heterosexual cohabitating family.

Correct Answer: 1 Rationale 1: An extended family contains a parent or a couple who share the house with their children and another adult relative.

Rationale 2: The traditional nuclear family consists of both biological parents, the children, and no other relatives or persons living in the household.

Rationale 3: 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.

Rationale 4: A heterosexual cohabitating family consists of a heterosexual couple, with or without children, living together outside of marriage.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-2 Question 2 Type: MCSA During assessment of a child's biological family history, it is especially important that the nurse asking the mother for information uses the term "child's father" instead of "your husband" in the situation of a:

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1. Traditional nuclear family.

2. Two-income nuclear family.

3. Traditional extended family.

4. Heterosexual cohabitating family.

Correct Answer: 4 Rationale 1: In the traditional nuclear family, the child's father is the same person as the mother's husband.

Rationale 2: The two-income nuclear family consists of children living with both biological parents where both parents are employed. The child’s father is the same person as the mother’s husband.

Rationale 3: In the traditional extended family, the child's father is the same person as the mother's husband. In this family group, there will be other adult relatives living as a member of the family.

Rationale 4: The couple in a heterosexual cohabitating family is not married, so no husband exists; the nurse should be asking about the child's father.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-2 Question 3 Type: MCSA 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. Traditional nuclear family.

2. Extended family.

3. Binuclear family.

4. Single-parent family.

Correct Answer: 4

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Rationale 1: The traditional nuclear family has two adults who can share in the care and nurturing of its children.

Rationale 2: The extended family generally has two or more adults who can share in the care and nurturing of its children.

Rationale 3: The binuclear family generally has at least two adults who can share in the care and nurturing of its children.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2-2 Question 4 Type: MCSA 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. Ask the parents, "What rule is hardest for your child to obey?"

2. Ask the children what happens when they break the rules.

3. Ask the parents, "How often do you hug or kiss your children?"

4. Observe the parent interacting with the child for five minutes.

Correct Answer: 2 Rationale 1: Learning about rules is less helpful than is an explanation of enforcement efforts and success.

Rationale 2: Parental styles are assessed while the family explains how it handles situations that require limit setting.

Rationale 3: Learning about how the parents express affection will not provide adequate information about parenting styles.

Rationale 4: While under short term observation, parental behavior may not be accurate. A less complete picture of parenting style is obtained during a brief artificial observation.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-3 Question 5 Type: MCSA The nurse is working on parenting skills with a group of mothers. Which style of parenting tends to produce adolescents who tend to be self-reliant and socially competent?

1. Authoritarian 2. Permissive 3. Indifferent 4. Authoritative Correct Answer: 4 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.

Rationale 2: Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors.

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

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 6 Type: MCSA 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. Experiencing consequences of misbehavior.

3. Reasoning.

4. Behavior modification.

Correct Answer: 4 Rationale 1: Time-out involves removing the child to an isolated, toy-free area for a short period of time to demonstrate that there are consequences of misbehavior.

Rationale 2: Experiencing consequences allows the child to learn that misbehavior results in negative experiences, such as losing privileges.

Rationale 3: Reasoning involves discussions about behaviors to help the child understand positive and negative behaviors.

Rationale 4: Behavior modification reinforces good behavior by giving rewards for desired behaviors.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-3 Question 7 Type: MCSA 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. Interrupted Family Processes related to a child with significant disability requiring alteration in family functioning.

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

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

4. Compromised Family Coping related to multiple simultaneous stressors.

Correct Answer: 4 Rationale 1: The spica cast might require alteration in family functioning; however, the situation describes no signs and symptoms to indicate this. In addition, fractures generally are not considered a significant long-term disability.

Rationale 2: The need for a spica cast is not considered a newly acquired disability. Nothing about the situation describes caregiver role strain.

Rationale 3: Lack of family members and lack of respite support were not mentioned in the scenario.

Rationale 4: The situation describes multiple changes, or stressors, in the family’s situation that compromise family coping skills.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2-4 Question 8 Type: MCSA Several children arrived at the emergency department accompanied only by their fathers. The nurse knows that the father who legally may sign emergency medical consent for treatment is: 1. The non-biologic one from the heterosexual cohabitating family.

2. The divorced one from the binuclear family.

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

4. The stepfather from the blended or reconstituted family.

Correct Answer: 2 Rationale 1: The non-biologic father from the heterosexual cohabitating family does not have legal authority to seek emergency medical care for the child.

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Rationale 2: The divorced father from the binuclear family may sign informed consent because he has equal legal rights with the mother under joint custody arrangements.

Rationale 3: When the single-parent mother has custody, the divorced non-biologic father does not have legal authority to seek emergency medical care for the child.

Rationale 4: The non-biologic stepfather from the blended or reconstituted family does not have legal authority to seek emergency medical care for the child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2-5 Question 9 Type: MCSA The camp nurse is assessing a group of children attending summer camp. Which child will be most likely to have problems perceiving a sense of belonging?

1. The child whose parents divorced recently 2. The child recently placed into foster care 3. The child whose mother remarried and who gained a stepparent recently 4. The child adopted as an infant Correct Answer: 2 Rationale 1: Children whose parents divorce often fear abandonment.

Rationale 2: Children in foster care are more likely to have problems perceiving a sense of belonging.

Rationale 3: Children who gain a stepparent might have problems trusting the new parent.

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-5 Question 10 Type: MCSA 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. Assumes the role of an expert professional to direct the health care.

2. Encourages the parents to stay with and comfort the child during an invasive procedure.

3. Assumes the role of a healthcare authority and intervenes for the child and family as a unit.

4. Tells the family what must be done for the family's health.

Correct Answer: 2 Rationale 1: Directing the care as a professional 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.

Rationale 2: Encouraging parents to be present during procedures 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.

Rationale 3: Intervening for the family as a health care authority 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2-6 Question 11 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA 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. Select the most relevant family assessment tool.

2. Establish a trusting relationship with the family.

3. Focus primarily on the mother, learning her greatest concern.

4. Observe the family in the home setting, since this step always proves indispensable.

Correct Answer: 2 Rationale 1: There is benefit when the tool used matches the family's strengths and resources; however, selecting the most relevant family assessment tool is not the initial step in obtaining a family assessment.

Rationale 2: Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment.

Rationale 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.

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-8 Question 12 Type: SEQ The nurse working in a family-centered hospital sees families at all stages of the family life cycle. Place each of the following families along the continuum of the family life cycle, beginning with the earliest stage and proceeding to the last stage.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The husband who retired from his job four years ago. He has been widowed six months.

Choice 2. Newlyweds Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Choice 3. Family with three children, ages 17, 13, and 9 Choice 4. Family taking their first child home from the birth hospital Choice 5. Family with grown children. Both parents hold full time jobs.

Choice 6. Family whose oldest child will start kindergarten next year and whose third child will be born shortly Correct Answer: 2,4,6,3,5,1 Rationale 1: Stage VIII--Family in retirement and old age. This is the final stage of the family life cycle.

Rationale 2: Stage I-- Beginning family. This is the first stage of the family life cycle.

Rationale 3: Stage V--Families with teenagers Rationale 4: Stage II--Childbearing family Rationale 5: Stage VII--Middle-aged parents Rationale 6: Stage III-- Families with preschool children Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2--6 Question 13 Type: MCSA A pediatric clinic serves several children who were adopted. The clinic nurse recognizes that the adopted child who is most likely to blame himself for being “given away” by the biologic parents is the: 1. Adopted child entering high school.

2. Child under three who was adopted as an infant.

3. Preschooler whose skin color is different from the adopted parents.

4. Child entering kindergarten.

Correct Answer: 4 Rationale 1: The adolescent often fantasizes about his biological parents.

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Rationale 2: This child does not understand adoption and doesn’t recognize himself as different from his parents.

Rationale 3: This child recognizes differences in appearance and enjoys hearing his “adoption story.”

Rationale 4: The five-year-old child is most likely to shoulder the blame for being “given up” by the biologic parents.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-5 Question 14 Type: MCMA While performing a family assessment, the nurse identifies which symptoms associated with dysfunctional family coping strategies?

Standard Text: Select all that apply.

1. Father acknowledges an addiction to alcohol.

2. The mother is a stay-at-home mother, and the father works two jobs to make ends meet.

3. The family has deep religious beliefs.

4. The father makes all of the decisions for the family, and the mother is compliant with the father’s decisions.

5. Direct, open communication among family members is observed.

Correct Answer: 1,4 Rationale 1: Drug and alcohol addictions are symptoms of dysfunctional coping strategies.

Rationale 2: This is a family decision related to family finances and preferences and is not a dysfunctional coping strategy.

Rationale 3: Spiritual supports are associated with functioning coping.

Rationale 4: This could be a symptom of extreme dominance and submission.

Rationale 5: This is a functional coping strategy.

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Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-4 Question 15 Type: MCSA As a component of the family assessment, the family assists the nurse in developing an ecomap. Prior to beginning the ecomap, the nurse explains that the ecomap: 1. Provides information about the family structure including family life events, health, and illness.

2. Illustrates family relationships and interactions with community activities including school, parental jobs, and children’s activities.

3. Is a short questionnaire of five questions that measures family growth, affection, and resolve.

4. Is a family assessment that consists of three categories of information about the family’s strengths and problems.

Correct Answer: 2 Rationale 1: Information of this type is called a genogram.

Rationale 2: This is the description of the ecogram.

Rationale 3: The five-item questionnaire measuring family growth, affection, resolve, adaptability, and partnership is a Family Apgar.

Rationale 4: This describes a Calgary Family Assessment Model.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-7

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Ball, Child Health Nursing, 3/E Chapter 3 Question 1 Type: MCMA A nurse is working with a pediatric client who is overweight. Which diseases are associated with pediatric obesity?

Standard Text: Select all that apply.

1. Cardiovascular disease 2. Asthma 3. Infant mortality 4. Diabetes Correct Answer: 1,4 Rationale 1: 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.

Rationale 2: Asthma is not targeted as one of the disease having roots in pediatric obesity.

Rationale 3: Infant mortality is not significantly correlated to obesity.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-1 Question 2 Type: MCSA 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: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Ethnicity African American, race Black 2. Ethnicity Black, race African American 3. Ethnicity Pentecostal, race African American 4. Ethnicity Southern, race Black Correct Answer: 1 Rationale 1: His ethnicity is African American and his race is Black because race refers to biological similarities.

Rationale 2: His ethnicity is African American because ethnicity refers to the distinctive characteristics of one's cultural background. His race is Black.

Rationale 3: His religion is Pentecostal, which would not be documented as religion is not part of ethnicity or race. His race is Black.

Rationale 4: His regional affiliation is Southern and his race is Black.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-1 Question 3 Type: MCSA The nurse is working with a child newly enrolled in an English as a Second Language class. The nurse wants to teach the child about the importance of hand washing before meals and to not eat food dropped on the exam room floor. The best way to evaluate the child’s understanding of hygienic nutrition is to: 1. Have the child repeat his interpretation of the information that was taught.

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

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

4. Have the nurse model proper hand washing before examining the child, and throw out the dropped cookie.

Correct Answer: 1

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Rationale 1: When an interpreter is not available, asking the client to repeat his understanding of what was taught reveals how he understood the concepts discussed.

Rationale 2: 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.

Rationale 3: Written materials in English hold minimal value for clients with limited understanding.

Rationale 4: The purpose of modeled behavior could be misunderstood if it is not accompanied by an explanation.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3-1 Question 4 Type: MCSA 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. African Americans 2. Native Americans 3. Asian Americans 4. Mexican Americans Correct Answer: 4 Rationale 1: African Americans are most likely to combine roots of voodoo, seen in Black Muslims, with Western health care prescriptions.

Rationale 2: Native Americans are most likely to combine the work of a medicine man with Western health care prescriptions.

Rationale 3: Asian Americans are most likely to combine acupuncture with Western health care prescriptions.

Rationale 4: Mexican Americans are most likely to combine curanderismo with Western health care prescriptions.

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Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-2 Question 5 Type: MCSA Unhappy with the treatment progress for their child with cancer, the parents choose to add dietary supplements, including megavitamins, as complementary medicine to the treatment plan. What would be the priority nursing diagnosis for this child?

1. Impaired gas exchange 2. Risk for injury 3. Altered family processes 4. Altered parenting Correct Answer: 2 Rationale 1: The use of complementary therapies does not indicate impaired gas exchange.

Rationale 2: Risk for injury is the priority nursing diagnosis when complementary therapies are used. The nurse must be concerned for the child's safety with respect to side effects, risks, and other implications of complementary therapy used with traditional Western medical treatments.

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

Rationale 4: There is no indication the parents are using inappropriate parenting styles.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3-4 Question 6 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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. Interrupted family processes related to shift in family roles secondary to demands of illness.

2. Fear related to separation from support system during hospitalization.

3. Noncompliance related to impaired verbal communication secondary to recent immigration from a nonEnglish-speaking area.

4. Spiritual distress related to discrepancy between beliefs and prescribed treatment.

Correct Answer: 3 Rationale 1: When one family member becomes ill, roles of other family members may be modified to meet the family’s needs. This is not a cultural variation.

Rationale 2: Any individual separated from her support system may experience fear. This is not a cultural variation.

Rationale 3: Noncompliance carries a negative bias. The inability to communicate effectively due to language differences does not mean the patient and/or family are noncompliant.

Rationale 4: If cultural beliefs are not in agreement with the treatment plan, this could lead to spiritual distress. It does not illustrate bias.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3-5 Question 7 Type: MCSA The nurse is beginning to obtain information about the present illness and medical history from the child's family.

The "zone" of space that the nurse should plan to use include the: 1. Public zone.

2. Personal zone.

3. Intimate zone.

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4. Social zone.

Correct Answer: 2 Rationale 1: The public zone involves a distance greater than six feet away from individuals and is used during communications with larger groups.

Rationale 2: The personal zone, 18 inches to three feet, is used when talking to individuals during interviewing and history taking.

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

Rationale 4: The social zone, three to six feet from the body, can be used when calling individuals from a waiting room.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-5 Question 8 Type: MCSA 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 is the school system like in your native land?"

4. "What does eye contact indicate?" and "When do you want me to make eye contact?"

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

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

Rationale 3: Leninger's sunrise model addresses educational differences.

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Rationale 4: Proximity, distance, and eye contact are concepts addressed by Giger and Davidhizar.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-6 Question 9 Type: MCSA 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 actually 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. Cambodian, Filipino, and Korean.

3. Canadian, Egyptian, and Haitian.

4. Brazilian, English, and Jewish.

Correct Answer: 2 Rationale 1: In France, Germany, and Ireland, the family name is listed second.

Rationale 2: The listed first name is in fact the family name in Cambodian, Filipino, and Korean cultures.

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

Rationale 4: In Brazil and England, and in Jewish culture, the family name is listed second.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-6 Question 10 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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. White 3. Hispanic 4. Black Correct Answer: 2 Rationale 1: Asians and Native Americans are more likely to experience alcohol abuse due to metabolic mechanisms.

Rationale 2: White children of certain geographic origins are more likely to manifest diseases such as cystic fibrosis and celiac disease.

Rationale 3: Hispanics and blacks have higher rates of lactose intolerance than those of other racial backgrounds.

Rationale 4: Blacks are more likely to experience obesity and sickle-cell disease.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-7 Question 11 Type: MCSA 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. Ask the mother about the cause of the bruise.

2. Call the Department of Social Services (DSS) to report this as a sign of abuse.

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

4. Chart the presence of a Mongolian spot.

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Correct Answer: 4 Rationale 1: Asking the mother about the cause of the bruise reveals cultural ignorance.

Rationale 2: 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.

Rationale 3: In choosing to confer with the physician, the nurse will reveal ignorance in culturally competent assessments.

Rationale 4: The nurse will chart the presence of a Mongolian spot, as this may be observed in races with dark skin tones.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-7 Question 12 Type: MCSA 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. Hispanic 2. Asian 3. Italian 4. Jewish Correct Answer: 2 Rationale 1: Individuals from Hispanic cultures are not less likely to express severe pain.

Rationale 2: Individuals from Asian cultures are more likely to remain quiet when experiencing pain.

Rationale 3: Individuals from Italian cultures are not less likely to express severe pain.

Rationale 4: Individuals from Jewish cultures are not less likely to express severe pain.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-7 Question 13 Type: MCSA 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. In certain cultural groups, health care decisions typically are made by the father. Therefore, the nurse should direct teaching efforts to the fathers in which cultures?

1. European American 2. African American 3. Native American 4. Appalachian Correct Answer: 4 Rationale 1: European American cultures are usually more egalitarian.

Rationale 2: These patterns are matriarchal in some African American cultures.

Rationale 3: Tribal elders might make the decisions in some Native American cultures.

Rationale 4: Family dominance patterns in some Appalachian cultures are more likely to be patriarchal.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-8 Question 14 Type: MCSA

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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, "What do you think caused the child's illness?"

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

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

4. Ask, "How do the child and family's religious and spiritual beliefs impact their practices for health and illness?"

Correct Answer: 2 Rationale 1: Asking about practices, possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

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

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

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-8 Question 15 Type: MCMA Access to health care often is less accessible to many groups of children and parents. Which factors can contribute to reducing access to health care?

Standard Text: Select all that apply.

1. Transportation problems 2. Lack of community healthcare facilities 3. Lack of health insurance among low-income families Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. Overload of clients resulting in inability to be seen in a timely fashion 5. Communication difficulties if the family is unable to speak or read English Correct Answer: 1,3,5 Rationale 1: Individuals who do not have free or affordable access to transportation may be unable to seek medical care when needed.

Rationale 2: Healthcare facilities are available nationwide. Although urban areas will have a larger number of facilities in this country, healthcare facilities would be available within the county or region.

Rationale 3: Even with the wide availability of healthcare facilities, many of these facilities will not accept clients without insurance or the ability to pay.

Rationale 4: While many healthcare facilities have an overabundance of clients, new facilities are opening up regularly. Walk-in, urgent care facilities are available in more communities.

Rationale 5: Communication difficulties may be a barrier to health care.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-3 Question 16 Type: MCMA A new nurse takes a job in a clinic that works with immigrants from many different cultures. The nurse recognizes that to be culturally sensitive, the nurse will need to: Standard Text: Select all that apply.

1. Determine means to indoctrinate the patients in the American culture.

2. Gain knowledge about the cultural groups attending the clinic.

3. Avoid the use of interpreters to reduce the impression of a bias.

4. Honor the cultural variations of the patients at the clinic.

5. Acquire information and educational media, such as pamphlets and teaching videos, that use languages spoken by the cultural groups attending the clinic.

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Correct Answer: 2,4,5 Rationale 1: Providing information about differences in culture is acceptable practice, but it is not appropriate to indoctrinate patients to the nurse’s own culture.

Rationale 2: In order to be culturally sensitive, it is appropriate to learn as much as possible about the cultures that live within the area served by the clinic.

Rationale 3: Interpreters will improve communication and should be utilized if necessary.

Rationale 4: Accepting cultural variations is important in being culturally sensitive.

Rationale 5: Being able to provide information in the languages spoken by groups that attend the clinic will help reduce barriers to communication.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3-8 Question 17 Type: MCSA A child has been admitted to the hospital for treatment of otitis media. When explaining to the mother that the child will be treated for an ear infection, the mother states: “Oh, it is important that my child receives hot foods to help my child.” Recognizing that this is a cultural preference and that ear infections are “cold conditions,” the nurse will include which of the following in the child’s diet?

1. Cheese and eggs 2. Chicken and fish 3. Fresh fruits and vegetables 4. Goat meat and raisins Correct Answer: 1 Rationale 1: Cheese and eggs are considered “hot” foods in many cultures and are used to treat cold conditions.

Rationale 2: Chicken and fish are considered to be “cold” foods and treat “hot” conditions, such as diarrhea.

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Rationale 3: Fresh fruits and vegetables are considered “cold” foods and treat “hot” conditions, such as constipation and fever.

Rationale 4: Goat meat and raisins are considered “cold” foods and treat “hot” conditions, such as kidney problems and sore throats.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-8 Question 18 Type: MCSA After reading a magazine article on complementary medicine methods, a teenager diagnosed with cancer asks the nurse about the possibility of adding CAM to the medical treatment plan. The nurse would explain to the child that prior to deciding on a CAM method, the adolescent must discuss: 1. The cost of the CAM with her parents.

2. The availability of CAM leaders with the hospital social worker.

3. The safety of the chosen CAM modality with her primary physician.

4. Alternative CAM methods with the nurse.

Correct Answer: 3 Rationale 1: Although discussion about cost is important, this is not the best response.

Rationale 2: Some CAM modalities may require an instructor/leader, and others may not. This is not the best answer.

Rationale 3: The priority concern about CAM modalities must be safety and the reaction of the CAM with the current medical treatment Rationale 4: In considering CAM modalities, the patient and family may have options. It is acceptable to discuss this with a nurse, but safety should always be the primary concern.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3-8

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Ball, Child Health Nursing, 3/E Chapter 4 Question 1 Type: MCSA The nurse teaches children with genetic disorders ways to maintain health and avoid complications. The nurse will teach children with which genetic disorder to follow medical guidelines and maintain penicillin prophylaxis?

1. Sickle-cell disease 2. Hereditary idiopathic scoliosis 3. Klinefelter's syndrome 4. Recklinghausen's disease Correct Answer: 1 Rationale 1: The client with sickle-cell disease needs penicillin prophylaxis to avoid complications of infection.

Rationale 2: The client with idiopathic scoliosis is experiencing an orthopedic deviation and does not need prophylactic penicillin.

Rationale 3: The client with Klinefelter's syndrome has a chromosomal alteration that does not require prophylactic penicillin.

Rationale 4: The client with Recklinghausen's disease has a genetic disorder affecting neural tissues that does not have complications that can be prevented by penicillin prophylaxis.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4-1 Question 2 Type: MCSA Which parent statement 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. "I was angry on the day he was conceived; that is why he got this sickness."

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2. "My nephews had chickenpox in my seventh month of pregnancy with my son, so that is how 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. "Our child is like this because I sunbathed too much during the pregnancy when I carried him."

Correct Answer: 3 Rationale 1: It needs to be reinforced to parents that the child’s condition is not because of something the parent did or did not do during the pregnancy. 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.

Rationale 2: The mother needs to understand that the child’s condition was not caused by an intrauterine infection or exposure to illness during her pregnancy.

Rationale 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.

Rationale 4: The mother needs to understand that the child’s condition is caused by a genetic condition. This will reduce shame and guilt on the mother’s part.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4-1 Question 3 Type: MCSA 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. About 25% of the boys born to the family will be affected.

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

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

Correct Answer: 1

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Rationale 1: The father must provide an X chromosome to the girl fetus. His X chromosome carries the disorder, so all of his daughters will be affected.

Rationale 2: None of the boys will receive the father's X chromosome, so none will be affected.

Rationale 3: All girls will receive the father's X chromosome.

Rationale 4: None of the boys will receive the father's X chromosome, so none will be affected.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-1 Question 4 Type: MCSA All five of the children in a family were 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. One parent has both chromosomes with the affected gene.

2. Both parents are carriers.

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

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

Correct Answer: 1 Rationale 1: 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.

Rationale 2: If both parents are carriers, 25% of the children should be free of the disease.

Rationale 3: For all five children to have the disorder, one parent would have to have both chromosomes affected.

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

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-3 Question 5 Type: MCSA 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. Phenylketonuria.

2. Turner's syndrome.

3. Huntington's chorea.

4. Marfan's syndrome.

Correct Answer: 4 Rationale 1: An early sign of phenylketonuria is an offensive urine odor that is found shortly after birth.

Rationale 2: Turner's syndrome, a congenital endocrine disorder, manifests with short stature and amenorrhea.

Rationale 3: 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.

Rationale 4: Marfan's syndrome is characterized by an arm span greater than one's height, a hollow chest, scoliosis, long digits, tall stature, and myopia.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-4 Question 6 Type: MCSA 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. X-linked recessive conditions Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. X-linked dominant conditions 4. Autosomal recessive conditions Correct Answer: 2 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.

Rationale 2: Multiple male miscarriages can be a sign of X-linked recessive conditions that can be severe and can result in high mortality rates.

Rationale 3: 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.

Rationale 4: 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%.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4-4 Question 7 Type: MCSA 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. Prominent epicanthal folds, resonant lungs, or absent tinnitus in Asian families.

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

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

4. Cleft lip and/or cleft palate, diaphragmatic hernia, or cataract.

Correct Answer: 4 Rationale 1: The trait of prominent epicanthal folds is a cultural variation in Asian families. Resonant lungs and the absence of ringing in the ears are normal findings.

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Rationale 2: A broad face is likely to be a family trait. Lichenification is thickening of the skin often due to chronic irritation. Spider angiomas are a common, benign skin lesion.

Rationale 3: A normocephalic head, euthyroid, and five digits per extremity are normal findings.

Rationale 4: Cleft lip and/or cleft palate, diaphragmatic hernia, or cataract may have a genetic basis, and the family may benefit from a genetic referral.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-4 Question 8 Type: MCMA 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: Standard Text: Select all that apply.

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

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

3. Child diagnosed at age six with cystic fibrosis.

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

5. Child with Duchenne muscular dystrophy being treated for respiratory symptoms.

Correct Answer: 3,5 Rationale 1: Although genetic disorders can lead to prematurity, there is no evidence that this child has a genetic disorder.

Rationale 2: There is no evidence that brain tumors have genetic tendencies.

Rationale 3: Cystic fibrosis is a genetic disorder inherited as autosomal recessive.

Rationale 4: Nephrotic syndrome is not known to be a genetic disorder.

Rationale 5: Duchenne muscular dystrophy is a genetic disorder inherited as X-linked recessive.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4-5 Question 9 Type: MCSA 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. Prenatal diagnostic testing.

2. Carrier screening.

3. Newborn screening.

4. Pre-implantation genetic diagnosis.

Correct Answer: 3 Rationale 1: Prenatal testing is performed to identify a fetus with a genetic disorder often involving amniocentesis and chorionic villi sampling. Diagnostic testing will confirm or rule out a diagnosis.

Rationale 2: Carrier screening involves testing an asymptomatic individual to determine carrier status.

Rationale 3: Newborn screening is used to test a large number of individuals for common genetic disorders, including phenylketonuria or sickle-cell and maple syrup urine disease. A newborn screening may contain false positives, so all positives must be confirmed with more extensive testing.

Rationale 4: Pre-implantation genetic diagnosis is performed on embryos prior to implantation to identify embryos with genetic disorders.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-5 Question 10 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

During genetic testing, one parent is found to have a chromosomal abnormality without any physical or mental disability; however, the offspring has inherited 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. Dominant-gene structural chromosomal inversions.

2. Mosaicism.

3. Dominant-gene structural chromosomal balanced translocations.

4. Dominant-gene structural chromosomal deletions.

Correct Answer: 3 Rationale 1: Individuals with other dominant-gene chromosomal alterations will all manifest some physical or mental abnormality themselves.

Rationale 2: 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.

Rationale 3: 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.

Rationale 4: A genetic deletion, such as is seen with cri du chat syndrome, results from a deletion on chromosome 5. This would be obvious in the parent as well as the child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-6 Question 11 Type: MCSA Following carrier testing, it is determined that both the husband and wife have sickle-cell trait. Which statement by the wife indicates correct understanding of autosomal recessive inheritance?

1. “Because both my husband and I carry the trait but do not have the disease, I don’t need to have prenatal testing because my baby will also be a carrier.”

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2. “Because both my husband and I are both carriers, I don’t need to have prenatal testing because all of our children will have the disease.

3. “When I become pregnant, I need to have an amniocentesis or other prenatal test to determine whether my baby is affected with sickle-cell disease.”

4. “There is no use undergoing prenatal testing as sickle-cell anemia cannot be diagnosed prenatally.”

Correct Answer: 3 Rationale 1: The pregnant woman will require prenatal testing as her child will have a 50-50 chance of being a carrier and a 1 in 4 chance of being affected.

Rationale 2: Each child has a 50% chance of carrying the trait and a 25% chance of having the disorder.

Rationale 3: This statement is accurate.

Rationale 4: This statement is inaccurate because sickle-cell anemia can be diagnosed prenatally.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4-6 Question 12 Type: MCSA 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. "I think going to the genetics clinic will help us get over the loss of our baby."

2. "I'm afraid the genetics clinic will tell us we cannot have another baby."

3. "The genetics clinic will prevent this from happening to us again."

4. "The genetics clinic will give us the information we need to decide whether we want to try again."

Correct Answer: 4 Rationale 1: Although information can help the grieving process, it will not resolve it.

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

Rationale 3: The clinic cannot prevent the loss of another baby, but can assist the parents to understand why this baby died and the risks of it occurring again.

Rationale 4: The genetics clinic provides information based on genetic findings about the risks of future pregnancies.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4-6 Question 13 Type: MCSA Advances in genetic screening provide information with high levels of certainty about genetic disorders a fetus might have. Which is an ethical implication of these advances?

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

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

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

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

Correct Answer: 2 Rationale 1: The nurse does not have to participate in any action contradictory to personal ethics.

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

Rationale 3: 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4-7 Question 14 Type: MCSA As medical care has evolved, it has become 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. Health care delivery is becoming more complex, despite these children requiring less care as they age.

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

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

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

Correct Answer: 3 Rationale 1: Children with genetic disorders typically require more care that is more complex.

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

Rationale 3: As advances in genetics continue, nurses will need to become familiar with more disorders in order to provide appropriate care for these children.

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

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-8 Question 15 Type: MCSA A child has been diagnosed as having a genetic disorder based on a mosaic trisomy. The nurse recognizes that the mother understands the significance of this diagnosis when she states: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. “Because my child has a mosaic trisomy, he will have some normal cells in his body, which means his disorder may not be as severe as in other children.”

2. “Children born with mosaic trisomy do not pass the disorder on to their children.”

3. “Mosaic trisomies are inherited from the father’s side of the family.”

4. “Mosaic trisomies occur in an ovum from an older woman.”

Correct Answer: 1 Rationale 1: A child with a mosaic trisomy has some cells containing 46 chromosomes and other cells containing 47 chromosomes. The degree the child will be affected by the disorder is based on the percentage of body cells that contain the 47 chromosomes.

Rationale 2: Mosaic trisomy may be passed on to future generations.

Rationale 3: Mosaic trisomies occur after fertilization of the ovum and involve an error in chromosomal division early in embryonic development.

Rationale 4: This statement is incorrect. Mosaic trisomies occur in early embryonic life.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4-2 Question 16 Type: MCMA The nurse is discussing autosomal recessive inheritance with a patient. The nurse will include which statements in the discussion?

Standard Text: Select all that apply.

1. “The disorder may appear to skip generations.”

2. “Boys and girls are affected in equal numbers.”

3. “The disorder passes from mother to son but not from father to daughter.”

4. “Daughters that are affected will be more severely involved than sons.”

5. “Both parents must be carriers for the disorder.”

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Correct Answer: 1,2,5 Rationale 1: In recessive disorders, one of the grandparents may have the disorder, the parent may not have symptoms of the disorder, and yet the child may be affected.

Rationale 2: Because this disorder is due to autosomal inheritance, it will affect males and females equally.

Rationale 3: This description describes sex-linked recessive inheritance.

Rationale 4: Severity will be equal between males and females.

Rationale 5: This is correct. Both parents must carry at least one of the affected genes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-2 Question 17 Type: MCSA A couple has been referred for genetic counseling. Prior to making the appointment, the couple should understand that: 1. The cost of genetic counseling will be covered by their health insurance.

2. Genetic counseling and testing is voluntary. They have a right to decide not to seek the information.

3. Once genetic counseling has been completed, the physician may require sterilization of the man or woman.

4. Their extended family will benefit from the knowledge the couple gains.

Correct Answer: 2 Rationale 1: Many insurance companies do not cover the cost of genetic counseling.

Rationale 2: Couples can decide whether or not to seek genetic counseling.

Rationale 3: The decision to have children or not to have children will be the couple’s. The purpose of genetic counseling is to help them make an informed decision.

Rationale 4: Not all family members will appreciate the knowledge and may prefer to remain uninformed.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-5

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Ball, Child Health Nursing, 3/E Chapter 5 Question 1 Type: MCSA While being comforted in the emergency department, the six-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 he can draw a picture.

3. 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.

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

Correct Answer: 3 Rationale 1: Ignoring the child's outburst will not help the child understand it really was not his fault.

Rationale 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 anything he said.

Rationale 3: 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.

Rationale 4: Addressing the sibling's needs and equipment reinforces the child's magical thinking that the trauma was his fault.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-1 Question 2 Type: MCSA

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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. Chronosystem.

2. Mesosystem.

3. Macrosystem.

4. Exosystem.

Correct Answer: 4 Rationale 1: The chronosystem involves the perspective of time in the child's life.

Rationale 2: The relationships of one microsystem to another involve a child's mesosystem.

Rationale 3: Political and cultural beliefs comprise a child's macrosystem.

Rationale 4: A child's exosystem is composed of the settings that influence a child even though she is not in daily contact with that system.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-2 Question 3 Type: MCSA The parents of a one-month-old infant are concerned that their baby seems different from their other child, and they 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 "slow-to-warm-up" child is that he: 1. Initially reacts to new situations by withdrawing.

2. Commonly has intense reactions to the environment.

3. Displays a predominately negative mood.

4. Shows a regularity in patterns of eating.

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Correct Answer: 1 Rationale 1: Slow-to-warm-up children adapt slowly to new situations and initially will withdraw.

Rationale 2: Commonly having intense reactions to the environment is a characteristic of "difficult" children.

Rationale 3: Displaying a predominately negative mood to the environment is a characteristic of "difficult" children.

Rationale 4: Showing regularity in patterns of eating is a characteristic of an "easy" child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-2 Question 4 Type: MCMA 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?

Standard Text: Select all that apply.

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

Rationale 2: Babies at 12 months tend to enjoy more colorful toys.

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Rationale 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.

Rationale 4: Toys that the child can manipulate and have music will draw the child’s attention.

Rationale 5: The 12-month-old child is learning to walk and will prize toys that promote mobility.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-3 Question 5 Type: MCSA While assessing the development of a nine-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 trying to determine whether the infant has developed: 1. Transductive reasoning 2. Conservation 3. Centration 4. Object permanence Correct Answer: 4 Rationale 1: Transductive reasoning is when a child connects two events in a cause-effect relationship because the events occurred at the same time.

Rationale 2: Conservation is when a child knows that matter is not changed when its form is altered.

Rationale 3: Centration is when a child focuses on only one particular aspect of a situation.

Rationale 4: A child who has developed object permanence has the ability to understand that even though something is out of sight, it still exists.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-3 Question 6 Type: MCSA A nurse is assessing language development in all the infants presenting at the physician's office for well-child visits. The nurse would want to evaluate the child further who is not able to verbalize the words “dada” and “mama” by the age of: 1. 18 months.

2. 8 months.

3. 5 months.

4. 12 months.

Correct Answer: 4 Rationale 1: By the age of 18 months, the child will have names for more people than just “mama” and “dada.”

Rationale 2: By eight months, infants will be making the sounds “mamamamam” and “dadadada” because they like to repeat sounds. At this time, they do not use these as names for the parents.

Rationale 3: A five-month-old infant makes sounds, but the sounds are not words.

Rationale 4: A child should be able to verbalize "mama" or "dada" to identify her parents by one year of age.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5-4 Question 7 Type: MCSA Two three-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.

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2. Solitary play.

3. Parallel play.

4. Associative play.

Correct 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. The school-age child participates in cooperative play.

Rationale 2: Solitary play is when a child plays alone. Infants’ play style is described as solitary.

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

Rationale 4: Associative play is characterized by children interacting in groups and participating in similar activities. Preschoolers’ play style is associative.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-5 Question 8 Type: MCSA 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. Resilience 4. Centration Correct 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.

Rationale 2: Assimilation describes the child's incorporation of new experiences.

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Rationale 3: Resilience is the ability to maintain healthy function even under significant stress and adversity.

Rationale 4: Centration is the ability to consider only one aspect of a situation at a time.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-5 Question 9 Type: MCSA While trying to inform a five-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. "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."

2. "Please stop talking about your puppy. I need to tell you about your CT scan."

3. "I'll come back when you are ready to talk with me more about your CT scan."

4. Ignore the child's responses and continue discussing the procedure.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: 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.

Rationale 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.

Rationale 4: Ignoring the child's obvious lack of attention will not help prepare her for the upcoming procedure.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-5 Question 10 Type: MCSA The mother of a six-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 sometimes use called: 1. Repression.

2. Rationalization.

3. Fantasy.

4. Regression.

Correct Answer: 4 Rationale 1: Repression is the involuntary forgetting of uncomfortable situations.

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

Rationale 3: Fantasy is a creation of the mind to help deal with an unacceptable fear.

Rationale 4: The correct answer is regression, which is a return to an earlier behavior.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-6 Question 11 Type: MCSA Prior to giving an intramuscular injection to a two-and-a-half-year-old child, the most appropriate statement by the nurse would be: 1. "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."

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2. "We will give you your shot when your mommy comes back."

3. "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?"

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

Correct Answer: 1 Rationale 1: The most appropriate response would be to acknowledge the child's feelings and give him something to look forward to.

Rationale 2: Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time.

Rationale 3: Giving elaborate descriptions and using colorful language are inappropriate because the instructions are unclear and lengthy.

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

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-7 Question 12 Type: MCSA A 14-year-old with cystic fibrosis suddenly becomes noncompliant with the medication regimen. 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. Set up a meeting with some older teens who have cystic fibrosis and have been managing their disease effectively.

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

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

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Correct Answer: 2 Rationale 1: Interest in games might begin to wane at this age.

Rationale 2: Providing an adolescent with positive role models who are in her peer group is the intervention most likely to improve compliance.

Rationale 3: Adult opinions, even from a physician, could be viewed negatively and challenged.

Rationale 4: Threatening punishment could further incite rebellion.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-7 Question 13 Type: MCSA The home health nurse is visiting a family at home when the toddler has an “accident” and has a bowel movement in his diaper. The mother becomes angry with the child and calls him a baby for messing himself. The nurse considers Erikson’s theory and recognizes that the mother’s behavior may have an effect on the child’s: 1. Cognitive development.

2. Sense of independence.

3. Conscience.

4. Development of superego.

Correct Answer: 2 Rationale 1: Erikson’s theory is related to psychosocial development. The mother’s criticism will not affect the child’s ability to think.

Rationale 2: Erikson’s toddler stage is autonomy (independence) versus shame and doubt.

Rationale 3: Conscience is what controls our knowledge of right and wrong and is a component of Kohlberg’s theory.

Rationale 4: In Freudian theory, the superego is the moral and ethical system of the personality.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-4 Question 14 Type: MCSA The clinic administrator has suggested that the nurse teach all children newly diagnosed with diabetes in a single class to save nursing time. The children recently diagnosed range in age from 6 to 15. The argument the nurse will use in to advocate for more than one group session would be based on: 1. Freud’s theory of psychosexual development, which states that the six-year-old child’s sexual energy is at rest while the adolescent has developed mature sexuality.

2. Erikson’s psychosocial theory, which discusses how children learn to relate to others.

3. Piaget’s cognitive development theory, which says the six-year-old learns by concrete examples while the 15year-old can think abstractly.

4. Kohlberg’s theory, which says the young child is conventional in his thinking and will want to learn to please others while the older child can internalize values and will learn for his own principles.

Correct Answer: 3 Rationale 1: This theory would not explain why it would be best to separate the group by age.

Rationale 2: Erikson’s theory is about relationships, not learning ability.

Rationale 3: The younger child will need to handle the equipment and observe demonstrations while the older child will require more discussion and less demonstration.

Rationale 4: Kohlberg’s theory may explain the reasons the child learns the material but does not discuss the learning style.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 15 Type: SEQ As children grow and develop, their style of play changes. Place the following descriptions of play styles in order from infancy to school-age.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Plays beside but not with other children Choice 2. Plays games with other children and is able to follow the rules of the game Choice 3. Plays alone with play directed by others Choice 4. Plays with others in loose groups Correct Answer: 3,1,4,2 Rationale 1: This describes parallel play, seen in toddlers.

Rationale 2: This describes cooperative play, seen in the school-age child.

Rationale 3: This describes infant style play, called solitary play.

Rationale 4: This describes associative play, which is seen in the preschooler.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-3 Question 16 Type: MCSA A 10-year-old child has been struggling with his self-esteem. Which activity would best help this child have a positive resolution of Erikson’s Industry versus Inferiority stage?

1. Playing sports with his older brother and the brother’s friends.

2. Have his mother compliment him when he completes his homework.

3. Encourage the child to participate in boy scouts and earn badges.

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4. Suggest to the mother that she allow the child to babysit his younger siblings.

Correct Answer: 3 Rationale 1: This would not help the child develop a positive self-esteem because the older boys will be more skilled at the sport than this child.

Rationale 2: Positive reinforcement is beneficial but does not support the development of Industry.

Rationale 3: The badges will be a visible documentation of his accomplishments.

Rationale 4: The 10-year-old cannot safely babysit the younger children, and this is unrelated to Erikson’s sense of industry.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-5

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Ball, Child Health Nursing, 3/E Chapter 6 Question 1 Type: MCSA 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. "This hospital and its staff are extremely competent, and you are receiving the best possible care."

2. "Does your child have any allergies or take any medication routinely?"

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

4. "It sounds like you are upset with the care your child has received. Is that correct?"

Correct Answer: 4 Rationale 1: Disagreeing with the mother at this point would not be a therapeutic response.

Rationale 2: 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.

Rationale 3: Making excuses is not considered responding therapeutically.

Rationale 4: This response validates the mother's perceptions, and it provides an opportunity for the mother to clarify her concerns with the nurse and keep the lines of communication open.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-1 Question 2 Type: MCSA 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: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Shyness.

2. Anxiety.

3. Anger.

4. Interest.

Correct Answer: 2 Rationale 1: A person experiencing shyness might hide her hands and have minimal eye contact with the other person.

Rationale 2: All of these nonverbal behaviors typically are expressed in a person who is experiencing feelings of anxiety.

Rationale 3: A person who is experiencing anger might appear rigid or tense, clench her fist, or tap her fingers.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-2 Question 3 Type: MCSA While caring for an adolescent with cystic fibrosis, the nurse would best demonstrate friendliness and interest by engaging in which nonverbal behavior?

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

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

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

4. Standing over the client's bed while talking with him.

Correct Answer: 1 Rationale 1: Sitting at eye level and leaning forward while speaking with the client is most likely to convey friendliness and warmth.

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Rationale 2: Crossing the legs and leaning back slightly in the chair while talking with the client could be interpreted as withdrawal.

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

Rationale 4: Standing over the client's bed while talking with him might be perceived as dominating or intimidating to the client.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-2 Question 4 Type: MCSA In order to prepare a six-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. "Why are you crying? I thought that you were a tough kid."

4. "Don't worry a bit; this is just like a little mosquito bite."

Correct Answer: 2 Rationale 1: This statement may be confusing to the six-year-old child. In addition, it is telling the child what to do.

Rationale 2: This statement is an accepting response that lets a child know that it is okay to express feelings.

Rationale 3: This statement belittles the child's expressed feelings. Children should not be told to not cry.

Children and adults should be able to express their feelings.

Rationale 4: In order to maintain trust, it is important to be honest. To a child, an IV stick is not a mosquito bite.

Telling a child not to worry will not make the child feel better.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-4 Question 5 Type: MCSA The nurse caring for a nine-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. "Have you been to the playroom yet? Maybe when you get back from whirlpool we can check it out together."

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. "Some of the children I have worked with have told me that they worried about the whirlpool hurting them.”

Correct Answer: 4 Rationale 1: Ignoring or distracting from the current situation does not allow the child to feel able to open up to the nurse about his fears and concerns. In addition, children live in the present, and they will not look forward to the promise of a visit to a playroom in the future.

Rationale 2: This statement might be confusing and might frighten the child. “Leave” for whirlpool could be misinterpreted as “going away."

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

Rationale 4: This statement is most likely to encourage the child to discuss his own concerns about the procedure.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-4 Question 6 Type: MCSA 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. Touch them often during the communication to reassure them.

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

3. Shake their hands upon greeting them.

4. Look directly at them while talking with them.

Correct Answer: 3 Rationale 1: Touch is not used very often in Japanese culture, especially with casual acquaintances.

Rationale 2: Distant personal space is the cultural norm.

Rationale 3: Handshaking is acceptable in the Japanese culture.

Rationale 4: Direct eye contact is considered a sign of disrespect in Japanese culture.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-5 Question 7 Type: MCMA 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 nurse will utilize which interventions?

Standard Text: Select all that apply.

1. Closing the door to the room when speaking to the family or child 2. Avoiding the use of medical jargon 3. Inviting the family out to a movie to decrease their anxiety 4. Introducing self to the child and family 5. Sitting in a chair facing the family and child Correct Answer: 1,2,4,5

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Rationale 1: Providing privacy by closing the door during discussions is a therapeutic communication intervention.

Rationale 2: Medical jargon will interfere with the effectiveness of communication and will not establish a therapeutic environment.

Rationale 3: Socializing with clients and family outside of the hospital increases the risk of the nurse becoming emotionally over-involved, blurring her professional boundaries, and decreasing her ability to be therapeutic to the client and family.

Rationale 4: Introducing oneself will assist in beginning a therapeutic relationship with the child and family.

Rationale 5: The nurse is using nonverbal communication by sitting at eye level facing the family. The message is “I care about you, and I am making time to help you.”

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-5 Question 8 Type: MCMA The nurse caring for a Chinese American child should be aware that acceptable nonverbal communication patterns to use when giving information to the child’s father include: Standard Text: Select all that apply.

1. Handshakes between men only.

2. The father prefers not to be touched by strangers.

3. Avoiding direct eye contact when listening.

4. Distant personal space is preferred.

5. Touch is common with family members and close friends.

Correct Answer: 2,3,4 Rationale 1: Shaking hands between men only is characteristic of Eastern Indian culture.

Rationale 2: 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.

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Rationale 3: 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.

Rationale 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.

Rationale 5: Touch between family and close friends is more characteristic of the African American culture.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-5 Question 9 Type: MCSA While assessing an eight-month-old infant, the best strategy for the nurse to use to promote communication with the infant would be to: 1. Use touch, patting, and cuddling the infant.

2. Speak to the infant in low-pitched, soft tones.

3. Place the infant out of the parents' view to decrease distraction.

4. Lean over the infant's face and talk with forceful tones.

Correct Answer: 1 Rationale 1: Infants thrive on touch, and it is a significant form of communication for them.

Rationale 2: Infants prefer high-pitched, soft tones.

Rationale 3: Infants do not like to be separated from their parents.

Rationale 4: It can be scary for an unfamiliar adult to lean over an infant's face.

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Learning Outcome: 6-6 Question 10 Type: MCSA A non-Spanish-speaking nurse is working with a seven-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 parents, with the child acting as interpreter.

2. To give the discharge instructions to the child.

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

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

Correct Answer: 4 Rationale 1: A child's translation might be more self-serving than truthful, and the child may not be able to understand the instructions completely.

Rationale 2: A seven-year-old should not be the only person receiving discharge instructions, as this is not legally or developmentally appropriate.

Rationale 3: Using a translation book leaves too much room for a potentially inadequate translation by the nurse.

Rationale 4: Even though the family might have to wait before they can be discharged, the information is too important to rely on anything or anyone other than a trained interpreter.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-6 Question 11 Type: MCSA While the nurse is bathing a seven-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. "I am working tonight so I will be with you tonight while your mother is away."

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2. "Could you explain to me what you mean by sad?"

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

4. "Can you tell me more about how it makes you feel when your mom leaves?"

Correct Answer: 3 Rationale 1: 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.

Rationale 2: Asking the child to explain what is meant lets the child know the feelings experienced are important to the nurse.

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

Rationale 4: The nurse's wanting to know more about the child's feelings conveys caring for the child and is therapeutic.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-6 Question 12 Type: MCSA The nurse is attempting to take the blood pressure of a four-year-old child. The child is afraid of the sphygmomanometer. Which action by the nurse will help allay the child’s feelings of anxiety?

1. Explain to the child: “I am just going to take your blood pressure.”

2. Have the mother hold the child still while the nurse takes the blood pressure.

3. Allow the child to handle the equipment and then demonstrate how the equipment works.

4. Tell the child: “This won’t hurt. I’ve had it done a bunch of times.”

Correct Answer: 3 Rationale 1: When something is taken, it is often removed. This statement may cause the child to fear that something will be removed from his body.

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Rationale 2: This may accomplish the task, but it does not reduce the child’s fear of the procedure.

Rationale 3: This reduces the child’s tension and is developmentally appropriate for a four-year-old child.

Rationale 4: This does not reassure the child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-4 Question 13 Type: MCSA The nurse is working with a 14-year-old adolescent with an intellectual disability. The adolescent’s mental age is four. In explaining an X-ray to the adolescent, the nurse should explain: 1. To the adolescent in terms appropriate to a teenager.

2. To the parents and have them explain to their child.

3. As little as possible because the child will not understand anyway.

4. Using words that are in the vocabulary of a four-year-old without talking down to the adolescent.

Correct Answer: 4 Rationale 1: The adolescent’s mental age is that of a four-year-old. Explanations should be at a level a four-yearold child can understand.

Rationale 2: The nurse will explain the procedure to the parents, but the nurse should also explain to the adolescent in terms he can understand.

Rationale 3: The child has communication skills, and the nurse should explain in simple terms that the adolescent can understand.

Rationale 4: Use the child’s mental, not chronological, age when explaining procedures.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-7 Question 14 Type: MCSA Following a car accident, a four-year-old child was admitted to the pediatric intensive care unit. Both parents were injured in the accident and have been unable to visit. The child’s condition has stabilized, and the child is transferred to the surgical unit for the remainder of her hospitalization. The child has not expressed any feelings during the hospitalization. Which interventions might help the child express her feelings?

1. Asking the hospital chaplain to talk with the child 2. Use play therapy including mother, father, and child dolls.

3. Use journaling to allow the child to express herself.

4. Using humor by telling knock-knock jokes Correct Answer: 2 Rationale 1: A four-year-old child has limited understanding of religious values and would not benefit from talking to the chaplain.

Rationale 2: Play is the work of the child, and children are often able to express their feelings in play when they lack the verbal skills to express them.

Rationale 3: Journaling is appropriate for an older child, but this child does not have the ability to put thoughts into writing.

Rationale 4: Knock-knock jokes are appropriate for a four-year-old child but would not help the child express her feelings.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-4 Question 15 Type: MCSA

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A seven-year-old has just returned to the unit from the operating room after undergoing an appendectomy. When asked, the child states that his pain is a 1 on a scale of 0 to 10. Which finding makes the nurse question this response?

1. Lies rigid in bed, refusing to move 2. Eyes closed, flat effect 3. Turning away from the nurse, avoiding eye contact 4. Mother states that the child is in pain.

Correct Answer: 1 Rationale 1: Body language tells the nurse that he is in severe pain.

Rationale 2: The face does not display symptoms of pain. Painful expression on the face would include grimaces and lowered brows. Tears may or may not be present.

Rationale 3: This expression could indicate shyness, not pain.

Rationale 4: Although the mother knows her child, she is also anticipating the child is in pain. The child’s body language is a better indicator of pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-6

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Ball, Child Health Nursing, 3/E Chapter 7 Question 1 Type: MCSA During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip.

Which finding would strongly suggest this disorder?

1. Asymmetric thigh and gluteal folds 2. Positive Babinski's reflex 3. A negative Moro reflex 4. Flat soles with prominent fat pads Correct Answer: 1 Rationale 1: Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip and require follow-up with an ultrasound.

Rationale 2: A positive Babinski's reflex is a normal finding in a newborn.

Rationale 3: The Moro reflex involves both arms and legs. A positive Moro reflex is normal in the newborn. The absence of the Moro can indicate a brain or tissue injury.

Rationale 4: Flat soles are normal in newborns.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-1 Question 2 Type: MCSA The nurse is taking a health history from the family of a three-year-old child. Which statement or question by the nurse would be most likely to establish rapport and elicit an accurate response from the family?

1. "Tell me about the concerns that brought you to the clinic today."

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2. "Does any member of your family have a history of asthma, heart disease, or diabetes?"

3. "Hello, I would like to talk with you and get some information about you and your child."

4. "You will need to fill out these forms; make sure that the information is as complete as possible."

Correct Answer: 1 Rationale 1: 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.

Rationale 2: Asking about a number of items at once might be confusing to the family.

Rationale 3: 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.

Rationale 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-1 Question 3 Type: MCSA A nurse working in the newborn nursery notes that an infant is having frequent episodes of apnea lasting 10 to15 seconds without any changes in color or decreases in heart rate. Which intervention would be the most appropriate?

1. Continue to observe the infant and call the physician if the apnea lasts longer than 20 seconds.

2. Suction the infant's mouth and nares.

3. Call the physician immediately.

4. Turn the infant on its right side.

Correct Answer: 1

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Rationale 1: 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.

Rationale 2: There is no indication that suctioning is needed.

Rationale 3: It is unnecessary to inform the physician, as apnea lasting 10 to 15 seconds is normal in a newborn.

Rationale 4: Turning the baby is not necessary, as apnea lasting 10 to 15 seconds in a newborn is normal.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-3 Question 4 Type: MCSA The nurse is completing a physical examination of a four-year-old child. The best position in which to place the child for assessment of the genitalia would be: 1. Supine, with legs at a 50-degree angle.

2. Right side-lying.

3. In prone position, with knees drawn up under the body.

4. Frog-leg position.

Correct Answer: 4 Rationale 1: The child will not tolerate the legs at a 50-degree angle for long.

Rationale 2: There is no reason for a side-lying position, and the child will not tolerate holding the top leg up for long.

Rationale 3: Prone with knees drawn up will allow assessment of the anus, but it will not allow for visualization of the vaginal area.

Rationale 4: 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 well tolerated by the majority of children.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-5 Question 5 Type: SEQ Put the following nursing assessments of a toddler in the best order for the nurse to proceed (from first assessment to last assessment).

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Auscultation of chest Choice 2. Examination of eyes, ears, and throat Choice 3. Palpation of abdomen Choice 4. General appearance Correct Answer: 4,1,3,2 Rationale 1: Auscultation usually is less threatening to the toddler than is palpation, especially if the nurse first demonstrates using the stethoscope on a parent or a toy.

Rationale 2: The most uncomfortable, most invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat; therefore, this assessment should be performed last.

Rationale 3: Palpation can be more threatening than is observing or listening, so it should be completed after both.

Rationale 4: The nurse will begin the assessment by looking at the child. This can be done while the mother is holding the child and the nurse is talking to the mother. This environment will be neutral for the child and will not cause anxiety.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7-5 Question 6 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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 client’s history and physical are normal. The most appropriate intervention for the nurse to implement next would be to inform the child that: 1. This is a normal finding in adolescent males and that the breast tissue generally regresses by the time of full sexual maturity.

2. 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.

3. A pediatric endocrine consult is being arranged.

4. The healthcare provider is arranging a surgical consult for him.

Correct Answer: 1 Rationale 1: Gynecomastia, or breast enlargement, is a normal finding in adolescent males as they develop toward sexual maturity.

Rationale 2: The breast enlargement is not related to fat content but is normal in developing adolescent males.

Rationale 3: This is a normal finding, and an endocrine consult is not required.

Rationale 4: There is no reason for a surgical consult, as this is normal for adolescent males.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-6 Question 7 Type: MCSA A nurse caring for a nine-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.

Based on these physical findings, the nurse would be most concerned with assessing: 1. Skin integrity, especially in the lower extremities.

2. Level of consciousness.

3. Urine output.

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4. Range of motion and ankle mobility.

Correct Answer: 3 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.

Rationale 2: While there may be an underlying condition causing the edema that could later result in changes in level of consciousness, assessing level of consciousness based on these findings is unlikely to elicit the cause of the child’s edema.

Rationale 3: 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.

Rationale 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 8 Type: MCSA 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 physician suspects which congenital cardiac defect?

1. Tetralogy of Fallot 2. Ventricular septal defect 3. Pulmonary atresia 4. Coarctation of the aorta Correct Answer: 4 Rationale 1: There are minimal differences between upper and lower blood pressure readings in tetralogy of Fallot.

Rationale 2: There are minimal differences between upper and lower blood pressure readings in ventricular septal defect.

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Rationale 3: There are minimal differences between upper and lower blood pressure readings in pulmonary atresia.

Rationale 4: Normally, blood pressures in the lower extremities are the same or higher than upper-extremity 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 9 Type: MCMA A seven-year-old presents to the clinic with an exacerbation of asthma symptoms. On physical exam, the nurse would expect which of the following findings?

Standard Text: Select all that apply.

1. Increased tactile fremitus 2. Decreased vocal resonance 3. Bronchophony 4. Decreased tactile fremitus 5. Wheezing Correct Answer: 2,4,5 Rationale 1: An increase in tactile fremitus is indicative of pneumonia.

Rationale 2: Asthma causes a decreased vocal resonance, as edema makes it more difficult for the sound to project.

Rationale 3: Bronchophony is an increase in the intensity and clarity of transmitted sounds that also is indicative of pneumonia.

Rationale 4: The air trapping in the lungs that occurs with asthma causes a decrease in the sensation of vibrations or a decreased tactile fremitus.

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Rationale 5: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, and it is a condition frequently present in asthma exacerbations.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 10 Type: MCSA While inspecting a five-year-old child's ears with an otoscope, the nurse notes that the right membrane is red and there is an absence of light reflex. In view of these findings, which vital sign parameter would most concern the nurse?

1. Heart rate 2. Temperature 3. Blood pressure 4. Respirations Correct Answer: 2 Rationale 1: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.

Rationale 2: The red finding indicates that there is probably infection in the middle ear while the absence of life reflex indicates a bulging tympanic member, which is also associated with infection.

Rationale 3: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.

Rationale 4: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 7-7 Question 11 Type: MCSA 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. Genitourinary 2. Cardiac 3. Gastrointestinal 4. Respiratory Correct Answer: 3 Rationale 1: 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.

Rationale 2: Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

Rationale 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.

Rationale 4: Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: Question 12 Type: SEQ While evaluating development of children, the nurse notes that the development of secondary sexual characteristics follows a typical pattern. Place the appearance of secondary sexual characteristics in the female in order of appearance from earliest to latest.

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Standard Text: Click and drag the options below to move them up or down.

Choice 1. Appearance of pubic hair Choice 2. Menarche Choice 3. Breast budding Choice 4. Breast Tanner stage 5, areola strongly pigmented Correct Answer: 3,1,2,4 Rationale 1: Pubic hair is the second stage of Tanner development occurring around 11 years of age.

Rationale 2: The onset of menstruation usually occurs after the appearance of the first pubic hair.

Rationale 3: According to Tanner stages, the first stage of pubertal development in girls is the development of palpable glandular tissue of the breasts. Breast buds usually develop between 9 and 14 years of age.

Rationale 4: This is the final stage of breast development according to Tanner stage. It usually occurs between 12 and 18 years of age.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-6 Question 13 Type: MCMA The policy of the pediatric clinic is that head circumferences are performed at each visit, if appropriate. The nurse should plan to check head circumferences on which of the children being seen today?

Standard Text: Select all that apply.

1. One-month-old child who is coming for his first well-child visit 2. Two-month-old child with failure to thrive 3. Nine-month-old child with otitis media 4. 18-month-old well-child visit for a child with Down’s syndrome Correct Answer: 1,2,3,4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: The fontanels are open and the head will increase in size until two years of age.

Rationale 2: The posterior fontanel is closed or closing. The anterior fontanel is open and head circumference will increase. The head circumference should be monitored to make sure the failure to thrive is not affecting brain development.

Rationale 3: The anterior fontanel is still open, and the head circumference is still increasing slightly. Failure to see the increase could indicate the sutures have closed prematurely. The otitis media diagnosis is unrelated to the general assessment findings.

Rationale 4: The anterior fontanel is closed or closing. The head circumferences should be evaluated until the child is two years old. The diagnosis of Down’s syndrome does not change the need to monitor the child’s progress.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-8 Question 14 Type: MCSA The nurse wants to do a quick evaluation of a one-month-old infant’s hearing. Which assessment will provide the best information?

1. Examining the ear canal with an otoscope 2. Using a vibrating tuning fork placed against the child’s skull 3. Using tympanometry 4. Using a noisemaker in the infant’s presence to evaluate the child’s response Correct Answer: 4 Rationale 1: Inspection of the ear canal and membrane will not provide any information on the infant’s hearing ability.

Rationale 2: In a school-age child, this will test bone conduction, but it is not appropriate for an infant.

Rationale 3: Tympanometry is a tool to evaluate the movement of the tympanic membrane. Although related to sound transmission, it is not the best response.

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Rationale 4: This is a quick, simple evaluation of the child’s ability to hear sounds. The child’s response can be a stopping of activity, widening of the eyes, or turning toward the sound.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7-5 Question 15 Type: MCSA To accurately access blood pressure on a child, the nurse would select a cuff: 1. By the cuff label—infant, child, adult.

2. That covers 2/3 of the upper arm with a bladder that wraps around at least 80% of the circumference of the arm.

3. Based on availability as the size of the cuff will not influence the blood pressure.

4. That extends up to 50 % of the upper arm and the bladder covers 1/4 of the circumference of the arm.

Correct Answer: 2 Rationale 1: This does not determine the size of the cuff by the size of the child. In addition, the arm may not be used for the blood pressure assessment.

Rationale 2: This is an accurate measurement to determine cuff size.

Rationale 3: Blood pressure readings will be inaccurately high or low based on whether the cuff is too large or too small.

Rationale 4: This is incorrect and will result in a cuff that is too small.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-5 Question 16 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

While assessing a seven-year-old girl, the nurse notices a regular—irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. What is the most appropriate action for the nurse to take next?

1. Record the finding as normal.

2. Notify the physician.

3. Schedule an EKG. 4. Ask the mother if a murmur has been detected before.

Correct Answer: 1 Rationale 1: This is sinus arrhythmia and is a normal finding in children but not in adults.

Rationale 2: This is a normal finding. It should be recorded, not reported.

Rationale 3: Nurses do not order tests, including EKGs. Rationale 4: There is no evidence of a murmur in the stem. This is a normal finding.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-3 Question 17 Type: MCSA While assessing the blood pressure of an eight-year-old child, the nurse notes the following: Systolic sound is heard at 98, but the sound continues until it reaches 0. There is a distinct sound softening at 48. How should the nurse record this finding?

1. 98/48 2. 98/48/0 3. 98/0 4. 48/0 Correct Answer: 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: This is not the correct documentation. Korotkoff sounds were heard down to 0 mmHg. Rationale 2: This documentation correctly records the nurse’s findings.

Rationale 3: This is not the correct documentation as it does not include the qualitative change at 48.

Rationale 4: This reading eliminates the systolic sound.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-5 Question 18 Type: MCMA While assessing newborns, the nurse should differentiate normal findings from findings which require further evaluation and intervention. Which would be normal newborn findings?

Standard Text: Select all that apply.

1. Swelling over the occiput that crosses suture lines 2. Tiny white papules located primarily on the nose and chin 3. Tiny red macules and pustules that come and go, primarily on the trunk and extremities 4. When the Moro reflex is elicited, the right arm extends and returns to the body. The left arm remains resting against the chest.

5. Greenish discoloration of skin over the entire body that is not removed by the initial bath Correct Answer: 1,2,3 Rationale 1: By crossing suture lines, this finding indicates it is caput succedaneum, a normal finding after vaginal delivery. No further evaluation or treatment is needed.

Rationale 2: This is a description of milia, a normal finding. No further care is required.

Rationale 3: This is a description of erythema toxicum, a normal newborn finding that requires no further treatment.

Rationale 4: This Moro reflex is incomplete. Further evaluation is necessary to determine if there has been injury to the right arm and/or shoulder.

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Rationale 5: This is a description of a meconium-stained newborn. The passage of meconium has occurred at a more distant time, leading to the staining. The child will need to be evaluated for meconium aspiration.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-3 Question 19 Type: MCSA The nurse is assessing a newborn while the new parents watch. The nurse uses an ophthalmoscope to examine the back of the eye (the retina) and notes a positive red reflex. The nurse would explain to the parents that the red reflex indicates: 1. The absence of congenital cataracts.

2. The presence of intraocular hemorrhage.

3. The optic nerve has been traumatized during delivery.

4. Presence of amblyopia.

Correct Answer: 1 Rationale 1: The light of the ophthalmoscope is reflecting off the retina producing the red reflex. This indicates there is nothing preventing the transfer of light.

Rationale 2: The red reflex is a normal finding.

Rationale 3: The optic nerve is behind the retina and not visible.

Rationale 4: Amblyopia cannot be diagnosed at this time and is not evaluated with an ophthalmoscope.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 20 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCMA The nurse is assessing a new admission to the newborn nursery. Which physical findings suggest the infant was preterm?

Standard Text: Select all that apply.

1. The ear pinna quickly returns to original position after being bent manually.

2. The infant’s resting position is tightly flexed.

3. Labia widely separated with clitoris prominent.

4. Breast area barely perceptible with flat areola, no bud.

5. Sole creases do not extend the length of the foot.

Correct Answer: 3,4,5 Rationale 1: This finding is associated with fetal maturity.

Rationale 2: This finding is associated with fetal maturity. A preterm infant will rest with arms and legs extended.

Rationale 3: In the mature infant, the labia covers the perineal area, including the clitoris.

Rationale 4: This is an indication of immaturity associated with the preterm infant.

Rationale 5: This is an indication of a preterm infant.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-4

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Ball, Child Health Nursing, 3/E Chapter 8 Question 1 Type: MCMA The nurse working in the pediatric clinic performs many activities. Which of these nursing activities can be classified promoting health promotion and maintenance?

Standard Text: Select all that apply.

1. Administering the flu vaccine to infants from 6 to 23 months of age 2. Administering an antibiotic to a child with a diagnosis of acute otitis media 3. Teaching parents how to perform pulmonary drainage and cupping on their child with a respiratory infection 4. Instructing adolescents how to use dental floss 5. Discussing of daily feeding schedules for infants Correct Answer: 1,4,5 Rationale 1: Administering flu vaccines is a health promotion and/or maintenance activity.

Rationale 2: An acute ear infection (otitis media) is an illness; treatment would not be a topic for health promotion and maintenance.

Rationale 3: 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.

Rationale 4: Health teaching to the healthy child qualifies as health promotion and maintenance.

Rationale 5: Health teaching activities including discussing feeding schedules are a component of health promotion and maintenance.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-1 Question 2 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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 screening.

2. Health promotion.

3. Health maintenance.

4. Health assessment.

Correct Answer: 2 Rationale 1: The health screening involves looking at the immunization record to determine which immunizations are needed.

Rationale 2: The explanation the nurse gives the mother provides information about the immunization series 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.

Rationale 3: Health maintenance is exemplified by the actual administration of the immunization.

Rationale 4: A health assessment would be completed to determine what immunizations were needed.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-1 Question 3 Type: MCSA A mother says to a nurse, "I am so concerned about my 14-year-old daughter because 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. Moral conditioning.

2. Health maintenance.

3. Behavioral discipline.

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4. Health promotion.

Correct Answer: 4 Rationale 1: Moral conditioning is not an applicable choice.

Rationale 2: Because the mother has reported the daughter is already engaging in unethical behavior, 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.

Rationale 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.

Rationale 4: Health promotion includes strategies designed to improve the state of wellness.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-1 Question 4 Type: MCSA A mother brings her two-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago. Based on this information, which is the most appropriate action by the nurse?

1. Asking the mother to leave the room after obtaining the history 2. Obtaining a comprehensive history, including sociodemographic data 3. Focusing exclusively on the reported illness 4. Reviewing health promotion and maintenance activities Correct Answer: 4 Rationale 1: A two-year-old child will be more cooperative with the parent(s) present. The mother should remain with the child.

Rationale 2: Because the child is a regular at this office, there is no need to take a comprehensive history.

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Rationale 3: Focusing exclusively on the reported illness(es) ignores the opportunity to use health promotion strategies.

Rationale 4: A nurse should use every opportunity and office visit to review health promotion and maintenance activities.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-3 Question 5 Type: MCSA Which of these strategies would be most effective for a "teachable moment" for the parents of a four-year-old child during a routine office visit?

1. Discuss with the parents preparation for school because the child will start kindergarten next year 2. Review five-year-old anticipatory guidelines with the parents.

3. Select one topic that is a common problem or concern for parents of four-year-olds and present a brief amount of information on the topic.

4. Review all four-year-old anticipatory guidelines with the parents.

Correct Answer: 3 Rationale 1: Unless the parents raise the issue, preparation for school should be discussed closer to the event.

Rationale 2: Giving too much information to the parents at one time can result in them forgetting important information due to overload; selecting one topic and presenting information is appropriate.

Rationale 3: Children and families often learn best when presented with small bits of information.

Rationale 4: Giving too much information to the parents at one time can result in them forgetting important information due to overload; selecting one topic and presenting information is appropriate.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 8-3 Question 6 Type: MCMA Which nursing assessment activities should be included for the child and family at each health supervision visit?

Standard Text: Select all that apply.

1. Performing an age-appropriate developmental assessment 2. Performing age-appropriate screening examinations 3. Monitoring parents' ability to pay for services 4. Assessing for genetic abnormalities 5. Obtaining an updated health history Correct Answer: 1,2,5 Rationale 1: Age-appropriate developmental assessments are included at every health supervision visit.

Rationale 2: Screening examinations will differ as the child grows and health concerns change over time.

Rationale 3: A nurse would not assess the parents' financial status at each health supervision visit.

Rationale 4: Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Rationale 5: It is necessary to update the health history at every visit in order to be fully knowledgeable of the child’s needs.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-4 Question 7 Type: MCSA 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 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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. Ask each parent to complain to the nurse manager that there is not adequate time to talk with the nurse at each visit.

2. Perform a limited assessment based on reason for visit and provide pamphlets covering anticipatory guidance.

3. Focus anticipatory guidance strategies on topics in which the parent or child has expressed interest.

4. Plan to do the anticipatory guidance first, because either the nurse practitioner or the physician can perform an assessment of the child.

Correct Answer: 3 Rationale 1: Suggesting that parents complain to a nurse manager might be destructive to the needs of the children and parents, and it might adversely affect the operation of the nursing unit.

Rationale 2: Incomplete assessments may lead to health problems being overlooked. Pamphlets may be beneficial to supplement anticipatory guidance information but should not take the place of the nurse providing information directly.

Rationale 3: 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.

Rationale 4: Performing anticipatory guidance prior to history taking does not follow the nursing process.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8-5 Question 8 Type: MCSA 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. Which response by the nurse would promote family-centered communication?

1. "I agree with you; discipline is an important part of parenting."

2. "Tell me how you feel when your adolescent is aggressive with you."

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3. "You are so right. Adolescents function in the me-first mode all the time."

4. "I know just how you feel. I had the same experience with my children."

Correct Answer: 2 Rationale 1: This statement is a blocking statement and would not foster family-centered communication.

Rationale 2: Using an open-ended question allows the parents to discuss a family concern.

Rationale 3: This statement is a blocking statement and would not foster family-centered communication.

Rationale 4: This statement is a blocking statement and would not foster family-centered communication.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-6 Question 9 Type: MCSA A parent asks a nurse, "How do you know when my child needs these screening tests the doctor just mentioned?"

How should the nurse respond to the parent?

1. "Screening tests are done at each office visit."

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 administered at the ages when a child is most likely to develop a condition."

4. "Screening tests are most often done when the doctor suspects something is wrong with the child."

Correct Answer: 3 Rationale 1: Screening tests are not done at each office visit.

Rationale 2: Abnormal newborn screening tests require immediate follow-up.

Rationale 3: This response provides a definition for screening tests.

Rationale 4: Screening tests are done to detect the possibility of problems, not when a problem is suspected.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-6 Question 10 Type: MCSA The mother of a two-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. "Let's ignore this behavior. It will stop sooner."

2. "What do you usually do or say during a temper tantrum?"

3. "This is definitely a temper tantrum. I know exactly what you are feeling right now."

4. "Pick up and cuddle your child now, please."

Correct Answer: 2 Rationale 1: Ignoring the behavior is not an effective way to problem solve for temper tantrums.

Rationale 2: 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.

Rationale 3: Sympathizing with the mother may make the mother feel better at that moment but does not help the mother improve her child’s behavior.

Rationale 4: Cuddling the child will provide positive reinforcement to the child to continue that behavior.

Providing a direct instruction to the mother in this manner is unlikely to elicit the mother’s trust in the nurse.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-7 Question 11 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

During a well-child visit, the nurse asks the mother of a six-month-old infant, "Does your baby sit without assistance?” and “Is the baby crawling?" Which process is the nurse using in this interaction?

1. Disease surveillance 2. Health promotion 3. Health maintenance 4. Developmental surveillance Correct Answer: 4 Rationale 1: The questions asked in the stem are not classified as disease surveillance questions; they are developmental surveillance questions.

Rationale 2: While health promotion and maintenance activities are related to developmental surveillance, these questions are looking specifically at the milestones; therefore, the answers health promotion and health maintenance are incorrect.

Rationale 3: While health promotion and maintenance activities are related to developmental surveillance, these questions are looking specifically at the milestones; therefore, the answers health promotion and health maintenance are incorrect.

Rationale 4: The questions asked by the nurse are seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-7 Question 12 Type: MCSA A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child and notes that the parents have missed the last two health care visits. The nurse also notes that the child has not received the second measles, mumps, and rubella (MMR) vaccine. The nurse should: 1. Plan to discuss the principles of health supervision at the next scheduled visit.

2. Call the parents and encourage them to bring the child for recommended care.

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3. Notify the physician that the child's immunizations are no longer up to date.

4. Speak firmly with the parents at the next health care visit about the importance of being compliant.

Correct Answer: 2 Rationale 1: 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.

Rationale 2: Partnering with the parents and encouraging them to follow health supervision guidelines is the best strategy to use.

Rationale 3: The nurse is responsible for reviewing the health supervision of the child, and there is no reason to abdicate this to another health professional.

Rationale 4: Speaking firmly with the parents about compliance will alienate the parents at this time.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-8 Question 13 Type: MCMA The nurse wants to perform developmental screenings on a five-year-old child. Which screening tools would be appropriate for this purpose?

Standard Text: Select all that apply.

1.

Denver II 2. Bayley Infant Neurodevelopmental Screener 3. McCarthy Scales of Children’s Abilities 4. Denver Articulation Screening Exam 5. Early Language Milestone Scale Correct Answer: 1,3,4

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Rationale 1: The Denver Developmental Screening Tool II is appropriate for children up to 6 years of age and tests fine and gross motor, language, and personal-social areas.

Rationale 2: This screening tool is appropriate for children ages 3 to 24 months and assesses neurodevelopmental skills.

Rationale 3: This test evaluates children between 2.5 and 8.5 years and evaluates motor, visual, and general cognitive skills.

Rationale 4: The test, designed for ages 2.5 to 6 years, evaluates speech.

Rationale 5: This test is used on children from birth to 36 months and evaluates auditory and visual components of speech.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-7 Question 14 Type: MCSA The nurse is evaluating the developmental skills of an eight-month-old child recently adopted from a foreign country. The nurse attempts to get the child to wave “bye-bye” and to play “patty-cake.” When the child is unable to perform either skill, the nurse should: 1. Document developmental delay on the child’s record.

2. Refer the child for an electroencephalogram.

3. Encourage the parents to seek medical attention for the child’s developmental delay.

4. Recognize that this child’s language skills and previous experience may not allow for these activities at this time.

Correct Answer: 4 Rationale 1: This quick assessment indicates only the child does not perform these skills, and a developmental delay cannot be based on this finding only.

Rationale 2: This is not a nursing intervention and would not determine developmental delay.

Rationale 3: Developmental delay is an assumption that cannot be confirmed at this time Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: This is a reality for many children adopted from foreign countries. It is appropriate for the nurse to continue to monitor the child’s development in future health care visits.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-7 Question 15 Type: MCSA A new patient is admitted to the pediatric clinic. The nurse wants to partner with the parents in creating a health care home. The first step for the nurse in becoming an effective partner with the parents would be to: 1. Develop a relationship with the parents with open supportive communication and display an interest and a concern for the family’s goals.

2. Determine the family’s financial stability and identify community resources.

3. Provide the parents with the nurse’s home phone number so the parents can call when they need information.

4. Remind the parents that it is necessary for the child to receive health supervision on a regular basis.

Correct Answer: 1 Rationale 1: A relationship must develop before a partnership can be developed.

Rationale 2: As a component of the partnership, community resources will be utilized, but that will occur after a relationship is developed. The nurse does not determine financial stability.

Rationale 3: It is inappropriate for the parents to call the nurse outside the clinic.

Rationale 4: While it is appropriate for the child to receive regular health supervision, reminding the parents of this need is not the first step in developing a partnership.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8-8 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 16 Type: MCMA A four–year-old child is seen in the pediatric clinic for a well-child visit. During this visit, the nurse recognizes that appropriate assessments that should be completed at this time include: Standard Text: Select all that apply.

1. Height and weight.

2. Head circumference.

3. Four-year-old required immunizations.

4. Developmental assessment.

5. Safety counseling.

Correct Answer: 1,3,4,5 Rationale 1: The child’s height and weight are measured at every healthcare visit.

Rationale 2: Head circumference is measured only in the first two years of life. Sutures close at that time, eliminating the need to monitor.

Rationale 3: Four-year-old children are seen for healthy child visits once a year. The immunizations should be given at this time.

Rationale 4: Developmental assessment is done at every healthy child visit.

Rationale 5: Safety counseling is a part of every health care visit.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-7

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Ball, Child Health Nursing, 3/E Chapter 9 Question 1 Type: MCSA During the visit to the pediatric office, a nurse observes the mother frequently looking at and massaging her infant.

Based on these observations, the nurse's conclusion should be: 1. That the mother is displaying positive maternal-infant attachment.

2. That the mother is trying to show the nurse that she can be affectionate to the infant.

3. That there is insufficient data to assess the mother-infant relationship.

4. That the mother might be overwhelmed by the demands of infant care.

Correct Answer: 1 Rationale 1: These behaviors are characteristic of a positive maternal-infant attachment.

Rationale 2: 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.

Rationale 3: These are behaviors indicative of positive attachment and sufficient to assess the mother-infant relationship at this time.

Rationale 4: There is no information indicating the mother might be overwhelmed.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-1 Question 2 Type: MCMA Which activities should the nurse in the newborn unit perform prior to discharge from the birth hospital?

Standard Text: Select all that apply.

1. Perform a heel stick to obtain blood for the newborn screen.

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2. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids.

3. Administer a folic acid injection to the infant to prevent bleeding.

4. Perform a hearing screening.

5. Monitor feeding behaviors.

Correct Answer: 1,4,5 Rationale 1: The infant should be screened for state-mandated tests prior to discharge. One such test is for PKU, which is required by all 50 states. PKU should be screened 48 hours after the first formula feeding. If the child is discharged early, the blood will be drawn for screening before discharge and then the test will be repeated at an appropriate time.

Rationale 2: The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. This is a prime opportunity to complete a head-to-toe assessment.

Rationale 3: Vitamin K, not folic acid, is administered. Vitamin K is given prophylactically to prevent bleeding due to vitamin K deficiency.

Rationale 4: A hearing screening is performed on all newborn infants prior to discharge.

Rationale 5: The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-2 Question 3 Type: MCSA A mother who is bottle-feeding her newborn requests to be discharged 24 hours post-delivery, because the mother also has twin two-year-olds at home. The nurse should schedule the follow-up visit for the newborn on which of these days?

1. Within 48 hours of discharge 2. When the infant is one month old 3. Within two weeks of discharge 4. Within one week of discharge Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: Newborns discharged before 48 hours old should be seen within 48 hours of discharge.

Rationale 2: A health supervision visit is routinely scheduled at one month of age regardless of age at time of discharge. Newborns should be monitored for jaundice, weight gain, umbilicus healing, and other problems; they should be evaluated 48 hours after early discharge.

Rationale 3: For an infant discharged at 24 hours, waiting two weeks after discharge increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice and failure to gain weight).

Rationale 4: Waiting one week 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).

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-4 Question 4 Type: MCMA The nurse in the newborn nursery is admitting a neonate. In order to determine the health and development of the newborn, what will the nurse assess?

Standard Text: Select all that apply.

1. Head and chest circumference 2. Weight and length 3. Body fat determination 4. Presence of newborn reflexes 5. Gestational age of the infant Correct Answer: 1,2,4,5 Rationale 1: The head circumference of a newborn should be larger than the chest circumference. Chest circumference greater than head circumference is associated with microcephaly and other problems.

Rationale 2: Weight and length should be plotted on a growth chart along with gestational age to determine if intrauterine growth was within the normal range.

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Rationale 3: Body fat determination is not a measure that is used during the newborn assessment.

Rationale 4: The newborn reflexes can be an indicator of a number of problems, including injuries to the extremities or the brain.

Rationale 5: Gestational age of the infant can predict health issues that can develop.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4 Question 5 Type: MCSA An infant weighs 9 pounds, 3 ounces at birth. When the infant is seven days old, the mother calls the pediatrician’s office worried about her child’s weight loss. What is the lowest acceptable weight the infant should be at this age?

1. 9 pounds 2. 8 pounds, 12 ounces 3. 8 pounds, 2 ounces 4. 7 pounds, 12 ounces Correct Answer: 3 Rationale 1: An infant would not be expected to lose only 3 ounces during the first week of life.

Rationale 2: 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth.

Rationale 3: 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 seven days of age.

Rationale 4: 7 pounds, 12 ounces would be too much weight loss for this infant.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-4 Question 6 Type: MCSA 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. Attempts to feed the infant.

3. Skin assessment.

4. Repositioning the head of the infant.

Correct Answer: 2 Rationale 1: There is no contraindication to assessing the heart and respiratory rate.

Rationale 2: 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 because the infant will be unresponsive to attempts at arousal and might be at risk for aspiration.

Rationale 3: There is no contraindication to assessing the infant's skin.

Rationale 4: Repositioning the head of the infant is acceptable to do while the infant is in a deep sleep.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-4 Question 7 Type: MCSA 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. 8 2. 6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. 12 4. 16 Correct Answer: 3 Rationale 1: This does not apply to the corrected age based on the infant being 12 weeks early.

Rationale 2: This is only half the time needed to adjust to the corrected age.

Rationale 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.

Rationale 4: This is more than the correction needed to determine the corrected age for this infant.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-6 Question 8 Type: MCSA 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. Place an infant hat on the head of the infant during sleep for the first three months of life.

2. Allow the infant to sleep on his abdomen while an adult is present and observing the infant during sleep.

3. Alternate the head position from left to right during sleep.

4. Wrap the occipital portion of the infant's head with an ace bandage for 20 minutes each day.

Correct Answer: 3 Rationale 1: An infant hat will not keep the occipital bones from flattening.

Rationale 2: The infant should not be allowed to sleep on his abdomen even when observed.

Rationale 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.

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Rationale 4: It is not necessary to wrap the infant's occipital portion of the infant's head.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-6 Question 9 Type: MCMA The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which of these instructions should the nurse give as disease/injury prevention strategies?

Standard Text: Select all that apply.

1. SIDS risk reduction 2. Fall prevention 3. Formula safety 4. Immunization schedule 5. Risk of poisoning Correct Answer: 1,2,3,4 Rationale 1: SIDS is a major concern of infancy, and information on SIDS prevention, including back sleeping and the use of fans for air movement, should be provided.

Rationale 2: Anticipatory guidance should be given about fall prevention. Newborns are incapable of protecting themselves from falls and must always be placed in a secure environment, including the use of bed rails and safety straps when appropriate.

Rationale 3: Parents must be instructed on safe handling of formula including preparation and storage guidelines.

Rationale 4: It is important for parents to understand the recommended vaccination schedules and to comply with these standards to protect their child from childhood illnesses.

Rationale 5: It is too early for a discussion on the risk of poisoning. Until the child is mobile, poisoning is not a high priority for client teaching.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-6 Question 10 Type: MCSA 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. Introduce solid foods beginning at four months of age.

2. Introduce table foods only after tooth eruption.

3. Breastfeed exclusively for the first year of life.

4. Following birth, begin exclusive breastfeeding with no water, juice, or other foods.

Correct Answer: 4 Rationale 1: A variety of solid foods should not be introduced at four months of age since the infant cannot digest many foods.

Rationale 2: Solid infant foods can be introduced at six months of age regardless of the status of tooth eruption since the foods are all pureed.

Rationale 3: The AAP does not recommend exclusive breastfeeding for the first year of life. These infants would be at risk for experiencing nutritional deficiencies.

Rationale 4: Breast milk is the preferred method of feeding infants in the first six months of life.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-8 Question 11 Type: MCSA A pregnant woman is planning to breastfeed. The nursing intervention that will promote breastfeeding in the new mother is: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Facilitating breastfeeding within the first 30 to 60 minutes of life.

2. Telling the mother that the physician strongly advises new mothers to breastfeed their newborns.

3. Encouraging the mother to attend breastfeeding classes before discharge from the hospital.

4. Giving the woman literature on breastfeeding as soon as she enters the labor room.

Correct Answer: 1 Rationale 1: The literature shows that the mother who has the opportunity to breastfeed her infant within the first 30 to 60 minutes after birth facilitates breastfeeding later.

Rationale 2: The mother will make the decision based on her feelings, not on what the physician says.

Rationale 3: 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.

Rationale 4: The mother in labor is not going to be able to focus on learning to breastfeed.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-8 Question 12 Type: MCSA Prior to discharge from the birth hospital, the new mother asks the nurse about the use of a mobile over the crib.

The nurse would explain to the mother that the mobile should be placed about 10 inches above the level of the baby. The nurse would explain that this placement: 1. Is based on the fact that newborns can focus at a distance of 8 to 12 inches.

2. Will prevent the infant from being injured by the mobile.

3. Is most convenient for the parents.

4. Is for decoration only. The newborn does not have vision sufficient to see the mobile.

Correct Answer: 1

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Rationale 1: This is correct information. In addition, the infant prefers the human face and black and white geometric patterns.

Rationale 2: There is no danger to the infant when the mobile is placed at this height, but that is not the reason for the placement.

Rationale 3: The purpose of the mobile is visual stimulation of the infant, not the convenience of the parents.

Rationale 4: This is incorrect information. The newborn does not have visual acuity equal to an adult but can focus at this distance.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-7 Question 13 Type: MCSA The nurse overhears the new parents discussing the care of the newborn. The father is heard to say, “We want to be careful not to spoil the baby by holding him too much.” The nurse will want to provide anticipatory guidance and might respond by saying: 1. “You are so right. A spoiled baby is hard to manage. Only pick the baby up when he needs to be fed.”

2. “It is important that the baby learns to soothe himself, so wait at least 15 minutes before you respond to his cries.”

3. “When the baby cries, offer him the bottle. If that doesn’t work, put him in his bed to cry it out.”

4. “Don’t worry about spoiling the baby by holding him. You will find both the baby and you will be better satisfied if you respond to the baby’s cries quickly and soothe him with your presence, voice, and touch.

Correct Answer: 4 Rationale 1: This is incorrect information. A baby cannot be spoiled by being held in the first six months of life.

Rationale 2: There is no reason to delay responding to the infant’s needs.

Rationale 3: This is incorrect information. Young infants cry for a purpose and will need adult intervention to resolve the issue.

Rationale 4: This is correct information.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-6 Question 14 Type: MCSA During a prenatal visit, the pregnant mother asks the nurse if she should have her baby’s cord blood collected and stored. The best response by the nurse would be: 1. “If I were pregnant, I would certainly bank by baby’s cord blood.”

2. “You wonder if you should have your baby’s cord blood banked?”

3. “Let’s discuss the pros and cons of cord blood banking.”

4. “What does the baby’s father think about cord blood banking?”

Correct Answer: 3 Rationale 1: It is inappropriate for the nurse to discuss her own decision about cord blood storage.

Rationale 2: This is a reflective answer used to get at the mother’s emotions. This is not an emotional situation.

The mother is asking for information.

Rationale 3: By starting the conversation with this statement, you are providing her with information so she can make an informed decision.

Rationale 4: While this may be brought into the discussion, it is not the best answer.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-5 Question 15 Type: SEQ

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A newborn is admitted to the nursery from the delivery room. All of the activities must be performed. Place the activities in order of performance from first to last.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Administer a vitamin K injection.

Choice 2. Take vital signs.

Choice 3. Place in an overbed warmer.

Choice 4. Administer eye prophylaxis.

Choice 5. Administer an admission bath.

Correct Answer: 3,2,4,1,5 Rationale 1: Vitamin K should be administered after eye prophylaxis for ease of administration.

Rationale 2: If the infant is showing signs of distress, admission procedures would be minimized to the essential to allow the newborn to transition.

Rationale 3: Cold stress is a main concern for newborns. They are wet from delivery and should be quickly dried and body heat maintained. While doing the head to toe assessment and monitoring the transition, the baby can best be observed if left uncovered and the external heat source of an overbed warmer provided.

Rationale 4: Eye prophylaxis should be performed within one hour of birth. It should precede the vitamin K injection.

Rationale 5: The admission bath is not administered until the baby’s vital signs have stabilized from birth and body temperature is within the normal range.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-6 Question 16 Type: MCMA While breastfeeding is recommended by the American Academy of Pediatrics, there are maternal and infant conditions that should be evaluated as being possible contraindications to breastfeeding. Some of these contraindications include: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Standard Text: Select all that apply.

1. The mother has heart disease.

2. The mother is infected with HIV. 3. The infant has been diagnosed with galactosemia.

4. The mother has small breasts.

5. The mother takes medications for a chronic health condition.

Correct Answer: 2,3,5 Rationale 1: While mothers who have heart disease may not be able to tolerate breastfeeding due to the added work load for the heart, it is not a contraindication.

Rationale 2: Since the AIDS virus is transmitted by blood and body fluid, breastfeeding would be contraindicated in this case.

Rationale 3: The infant with galactosemia cannot metabolize galactose, which is found in formula and breast milk.

Rationale 4: The size of the breasts do not serve as a contraindication to breastfeeding. Many women with small breasts successfully breastfeed.

Rationale 5: Most medications will appear in the breast milk. Therefore, each case should be considered individually. Until approved by the pediatrician, medication use should be a contraindication.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-8

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Ball, Child Health Nursing, 3/E Chapter 10 Question 1 Type: MCMA The nurse working with a family has observed that the older children have a large number of dental caries, so the nurse plans to provide the mother with information to prevent the development of dental caries in her new infant.

What instructions will the nurse include in the teaching provided to the mother?

Standard Text: Select all that apply.

1. Wiping the infant's gums with soft, moist gauze once or twice daily 2. Giving foods high in sugar only at breakfast time 3. Not allowing the infant to sleep with a bottle in the bed 4. Reminding the mother that dental care is not needed until the permanent teeth erupt 5. Using a topical anesthetic daily, beginning as soon as the first tooth begins to erupt Correct Answer: 1,3 Rationale 1: Wiping the infant’s gums with soft, moist gauze will help remove food particles from the gums.

Rationale 2: Foods high in sugar should be avoided in the infant period.

Rationale 3: Babies who are put to bed with a bottle often fall asleep with a mouth full of formula or juice. This fluid remains in contact with the upper teeth, making them susceptible to “bottle mouth syndrome.”

Rationale 4: Dental decay in the “baby” teeth can lead to oral health issues with the permanent teeth.

Rationale 5: Topical anesthetic should not be applied daily and does not improve oral health. Topical anesthetics will only reduce the pain of teething.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-2 Question 2 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

A nurse asks the mother to undress her four-month-old 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. "When you leave the office, only put one layer of clothing on your baby."

2. "My, you are dressing your infant warmly today."

3. "Did you think it was it cold when you left your home this morning?"

4. "I see that you have many layers of clothing on your baby. This could cause your baby's temperature to rise."

Correct Answer: 4 Rationale 1: 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; this statement is not helpful to the mother.

Rationale 2: Making a statement on how warmly the child is dressed will not necessarily accomplish the goal of informing the mother that she has overdressed the infant.

Rationale 3: This comment might cause the mother to become defensive, so it is not helpful to the mother.

Rationale 4: In this scenario, the mother has overdressed the infant. The nurse needs to inform the mother of this problem gently, and provide information to the mother on why it is a problem.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-4 Question 3 Type: MCSA The parents of an eight-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 attached to you. This is an expected infant response."

2. "Your baby seems to be afraid of the sitter. Why don’t you try another sitter?”

3. "Your infant is too young to be experiencing stranger anxiety; however, you might need to stop going out on Friday nights for a while."

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4. "Oh, don't worry. All infants and toddlers display these behaviors until at least 2½ years old."

Correct Answer: 1 Rationale 1: The best response is to explain to the parents about attachment behaviors and to provide assurance that this is a normal infant response.

Rationale 2: At eight months, separation anxiety is normal. There is no indication that the baby fears the sitter.

Rationale 3: Eight-month-old infants do experience stranger anxiety. Parents who take a break from parenting can be effective when they are with their infant, and they should not be encouraged to change this behavior.

Rationale 4: This is a non-therapeutic response. Infants usually stop experiencing stranger anxiety before 2½ years of age.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-4 Question 4 Type: MCSA 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. Surrounding the infant with toys and other stimulating items to encourage motor movement 3. Swaddling the infant 4. Putting the infant to bed each night at 8 p.m., even if the infant protests with crying Correct Answer: 2 Rationale 1: An infant seat restricts movement, which would not encourage muscle tone development.

Rationale 2: Encouraging movement best assists the infant to obtain good muscle tone.

Rationale 3: Swaddling the infant, while calming for a young infant, restricts movement.

Rationale 4: The bedtime has nothing to do with development of infant muscle tone.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-5 Question 5 Type: MCSA An infant is born at 24 weeks' gestational age. Which of these interventions should the nurse plan when the infant is discharged home?

1. Instructing the parents that infants need warmed milk and to heat the milk in a microwave for no more than 15 seconds 2. Giving the parents information on HIV screening that is necessary for infants born at this gestational age 3. Referring the infant for developmental screening 4. No particular instructions are necessary because discharge teaching is completed immediately after the birth of the infant.

Correct Answer: 3 Rationale 1: Milk should never be heated in a microwave. It is possible for “hot spots” to develop in the milk and burn the baby’s mouth.

Rationale 2: HIV testing would have been completed during the immediate newborn period.

Rationale 3: Premature infants need to be referred for developmental assessment soon after discharge from the hospital.

Rationale 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-6 Question 6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA 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. Placing the infant about 15 inches from the TV and turning on an infant show such as Sesame Street 3. Swaddling the infant 4. Allowing the infant to cry but observing the infant to prevent injury Correct Answer: 3 Rationale 1: Sucking can be a comfort measure for infants, but the infant should not be given her own fingers.

Rationale 2: Infants should not be watching television from any distance.

Rationale 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.

Rationale 4: The infant cannot be left to cry for several hours and should be taught to trust caregivers through swaddling.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-6 Question 7 Type: MCSA The nurse has been discussing behaviors to promote infant sleep with the mother of a two-month-old. Which statement by the mother indicates the need for additional discussion?

1. “I will read to my baby every night when getting him ready for bed.”

2. “I will not bring him into my bed when he is having trouble falling asleep.”

3. “I will have active play at bedtime to tire him out so he will sleep better.”

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4. “It is okay for my baby to have a “blankie” as a security object when he is put in his bed.”

Correct Answer: 3 Rationale 1: A regular bedtime routine helps the infant to transition into sleep. This statement does not require additional discussion.

Rationale 2: Co-sleeping is to be discouraged. It can be a safety issue for the infant and also interferes with the parents getting enough sleep. This does not require additional discussion.

Rationale 3: Active play immediately before bedtime will stimulate the baby and interfere with sleep. This response requires more information.

Rationale 4: This security object helps provide consistency to the routine. This statement does not require additional discussion.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10-6 Question 8 Type: MCSA A six-month-old infant has been hospitalized several times with diarrhea. The nurse evaluates home care to determine the cause of the repeated illnesses. Which is the most likely cause of the repeated gastroenteritis?

1. The infant is allowed to drink from her parents’ drinks at meal time.

2. If the infant doesn’t finish her bottle, the mother returns it to the refrigerator to be used later in the day.

3. There are three school-age children in the family.

4. The infant often wears only a diaper around the house.

Correct Answer: 2 Rationale 1: The parents are showing no symptoms of gastroenteritis, so this is probably not the cause of the infant’s problems.

Rationale 2: This practice would allow bacteria to grow in the milk and should be discontinued. Unfinished formula should be discarded.

Rationale 3: There is no evidence the other children have had any illnesses.

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Rationale 4: An infant who only wears a diaper is not more susceptible to diarrhea than other infants.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-3 Question 9 Type: MCMA The new mother tells the nurse that sometimes her infant seems to become frantic when crying and asks what she can do when this happens. Which actions would the nurse recommend?

Standard Text: Select all that apply.

1. Offer breast or bottle if it has been two hours or longer since the last feeding.

2. If the infant is not hungry or wet, allow the infant to cry it out.

3. Swaddle the infant in a blanket and rock the infant.

4. Try patting the infant on the back to help the baby expel gas.

5. Take the infant to a different room or outside to distract the infant.

Correct Answer: 1,3,4 Rationale 1: The infant may be hungry. This is appropriate.

Rationale 2: The infant needs help to regain control. The mother should comfort her infant.

Rationale 3: Swaddling is comforting to the infant. This is appropriate.

Rationale 4: This is an appropriate response.

Rationale 5: Babies in distress will not sooth by changing environments.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 10-5 Question 10 Type: SEQ Nurses need to know normal development so they can recognize infants who fail to meet developmental milestones. Place the following developmental milestones in order from the earliest to appear to the latest to appear.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Responds to name Choice 2. Waves bye-bye when directed Choice 3. Lifts head when prone Choice 4. Rolls from front to back Choice 5. Makes cooing sounds Correct Answer: 3,5,4,1,2 Rationale 1: This milestone usually occurs around nine months of age.

Rationale 2: This milestone usually occurs around 12 months of age.

Rationale 3: This is common in the one-month-old infant.

Rationale 4: This skill occurs around four months of age.

Rationale 5: This occurs around two months of age.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-3 Question 11 Type: MCSA The nurse is teaching a group of parents about car safety. Which statement by a parent requires additional teaching?

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1. “The safest place in the car for the baby is the middle of the back seat.”

2. “I will use a rear facing car seat for my baby.”

3. “I will take the car seat to the local police station for them to check placement and safety.”

4. “For the trip home from the birth hospital, I will bucket myself in the back seat and hold the baby carefully. I am borrowing a car seat and should have it by my next trip out.”

Correct Answer: 4 Rationale 1: This is correct information and does not require additional teaching.

Rationale 2: This is correct information and does not require additional teaching.

Rationale 3: This is a safe practice and does not require additional teaching Rationale 4: While the mother recognizes the need for the car seat, she hasn’t shown adequate preparation. The baby should not be discharged without a car seat in the car. The nurse will want to reinforce the need for a car seat on every trip and may need to help the mother find a way to obtain a car seat for the trip home.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10-5 Question 12 Type: MCSA The home health nurse visits a home with an eight-month-old baby. Which observation is a safety issue that should be discussed with the mother?

1. The infant crib mattress has been lowered to its lowest level.

2. The mother cuts hot dogs into pieces for the baby to “gum.”

3. The cords to the window blinds have been shortened and do not hang below the window.

4. The mother has placed infant barriers around the gas heat stove.

Correct Answer: 2 Rationale 1: This is appropriate for an eight-month-old as the infant will be pulling up and standing in the crib.

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Rationale 2: Hot dogs are associated with choking in young infants. Because infants have few teeth, they are unable to chew the hotdogs and may choke on them. Finger foods for infants should be limited to things that do not require chewing.

Rationale 3: This is an appropriate protective action that does not require additional teaching.

Rationale 4: This is appropriate to protect the crawling infant from burns.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-5 Question 13 Type: MCSA Which parental behavior presents a risk for the infant in the home?

1. The father admits smoking cigarettes in the home but says he never smokes around the baby.

2. The parents have parties once a month in the home and serve alcoholic beverages.

3. The parents allow their other children, ages six and 10, to supervise the infant while the parents are working in another room.

4. The mother is a diabetic and has insulin and syringes in the household.

Correct Answer: 1 Rationale 1: Cigarette smoke clings to clothing, skin, and the environment. This places the infant at risk for asthma, sudden infant death, and other diseases.

Rationale 2: Serving alcohol in the home is not a risk for the infant unless the caregiver becomes intoxicated.

Rationale 3: This is not inappropriate behavior as the parents are still in the house.

Rationale 4: This is not an uncommon problem and does not present a risk for the infant.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 10-3 Question 14 Type: MCSA The home health nurse is concerned that the teenage mother tends to watch television while feeding the baby rather than talking and playing with her baby. Which statement by the nurse will most likely encourage the mother to talk and play with the baby more?

1. “Babies who are talked to more have higher IQs later on.”

2. “You should talk to your baby more.”

3. “Watch how I talk to the baby and see if you can follow my lead.”

4. “Have you noticed how your baby looks at you when you speak? You can see how he knows your voice.”

Correct Answer: 4 Rationale 1: Although speaking to the baby is important for development, there is no guarantee that the baby will have a higher IQ. Rationale 2: Teenagers often rebel against authority figures. This statement comes across as instruction and may not be accepted by the mother.

Rationale 3: Teenagers do not like to be told what to do.

Rationale 4: This reinforces to the mother that the baby responds to her and may encourage the mother to talk to the baby more.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-4 Question 15 Type: MCSA The nurse has been following the infant in the well-baby clinic and has checked the child’s vision on every visit.

At four months of age, the nurse will add the cover-uncover test to check the child for: 1. Conjunctivitis.

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2. Strabismus.

3. Amblyopia.

4. Cataracts.

Correct Answer: 2 Rationale 1: Conjunctivitis is an infection of the conjunctiva and is diagnosed by appearance, not a test.

Rationale 2: Strabismus is crossed eyes and is evaluated by the cover-uncover test.

Rationale 3: Amblyopia is “lazy eye” and is a vision disorder. It is not tested by the cover-uncover test.

Rationale 4: Cataracts can be evaluated by viewing the retina, not by the cover-uncover test.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-2

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Ball, Child Health Nursing, 3/E Chapter 11 Question 1 Type: MCSA The nurse is explaining the primary purpose of performing health maintenance activities at each pediatric visit.

The best explanation touches on: 1. Planning appropriate disciplinary measures for control of behavior.

2. Reviewing developmental milestones with the parents.

3. Prevention of disease and injury.

4. Teaching growth and development to the parents.

Correct Answer: 3 Rationale 1: 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.

Rationale 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.

Rationale 3: The primary purpose of health maintenance activities is prevention of disease and injury for children of all ages.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-1 Question 2 Type: MCMA

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Which of these developmental milestones should the nurse expect to find in children who are between two and three years old?

Standard Text: Select all that apply.

1. Always feeds self 2. Throws ball overhand 3. Kicks a ball 4. Goes up and down stairs 5. Scribbles and draws on paper Correct Answer: 3,4,5 Rationale 1: Children between the ages of three and four years old feed themselves.

Rationale 2: Children between the ages of four and five years can throw a ball overhead.

Rationale 3: Children between the ages of two and three years old can kick a ball.

Rationale 4: Children between the ages of two and three years old can go up and down stairs.

Rationale 5: Children between the ages of two and three years old can scribble and draw on paper.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-1 Question 3 Type: MCSA 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 most important assessment data in monitoring the two-year-old child with obesity is: 1. Weight alone.

2. The child’s percentile score of height and weight and weight on the growth chart.

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3. Changes in the child’s percentile on the growth chart from birth to the present.

4. The child’s body mass index.

Correct Answer: 4 Rationale 1: Weight cannot be used alone; weight in comparison to height provides clearer information.

Rationale 2: This can be helpful information, but it compares this child’s height to the average child of this age and this child’s weight to the average to the average child. It does not look at this child’s height to weight comparison.

Rationale 3: Children’s percentile findings on the growth chart may change from one evaluation to the next as they alternate between growth spurts and periods of slower growth.

Rationale 4: The body mass index is a comparison of the child’s weight to height and is the best tool for evaluating obesity.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-3 Question 4 Type: MCSA A nurse is preparing to perform a physical assessment on a toddler. Which of these actions should the nurse take?

1. Explain each part of the examination to the child before performing it.

2. Ask the mother to tell the child not to be afraid.

3. Perform the assessment from head to toe.

4. Leave intrusive procedures, such as ear and eye examinations, until the end.

Correct Answer: 4 Rationale 1: Explaining each part before performing it will only make the child more fearful, as it will make the entire procedure last longer.

Rationale 2: This will do little to alleviate the child's fears.

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Rationale 3: The nurse should complete the assessment in whichever order does not upset the child, leaving the head and genital areas for last.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-3 Question 5 Type: MCMA The nurse recommends to the mothers of toddlers and preschoolers that they limit television to two hours a day.

The nurse also discusses promoting physical activities that are related to kinesthesia. Which activities would the nurse suggest?

Standard Text: Select all that apply.

1. Walking on a balance beam 2. Reading 3. Playing a memory game 4. Skipping 5. Giving up a pacifier Correct Answer: 1,4 Rationale 1: Kinesthesia is the sense of one's body position and movement, and it develops during the preschool years. Activities related to kinesthesia include skipping, walking on a balance beam, and throwing and catching a ball.

Rationale 2: Reading is a cognitive activity.

Rationale 3: Playing a memory game is a cognitive activity.

Rationale 4: Kinesthesia is the sense of one's body position and movement, and it develops during the preschool years. Activities related to kinesthesia include skipping, walking on a balance beam, and throwing and catching a ball.

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Rationale 5: A pacifier is used to soothe and calm infants.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-3 Question 6 Type: MCSA 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 would be the most appropriate action for the nurse to take?

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. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler's behavior.

4. Allow the toddler to stand on the floor until the crying stops.

Correct Answer: 2 Rationale 1: The father should not be asked to restrain the child for the entire examination.

Rationale 2: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way.

Rationale 3: If a child needs to be subdued, then another nurse should be the one to assist. However, in this case the goal is to calm the child so that the assessment can be completed.

Rationale 4: Allowing the toddler to stand on the floor is not going to calm the child so that the assessment can be completed.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 7 Type: MCSA 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. "I think you are not parenting your child properly, so let's talk about ways to improve your parenting skills."

4. "Can you try only spanking the child every other day for one week and see how that affects the child's behavior?"

Correct 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.

Rationale 2: The behavior reported by the parent was excessive. The only response that is appropriate is to seek a more positive way of influencing the child’s behavior.

Rationale 3: This comment is inappropriate, and it will cause the parents to become defensive of their actions.

Rationale 4: Making the suggestion for parents to spank even every other day is inappropriate.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-4 Question 8 Type: MCSA 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 cooperatively, while preschoolers play interactive games.

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3. Toddlers play house and imitate adult roles, while preschoolers become the "mom or dad" while playing house.

4. There are no differences between toddlers and preschoolers because both play cooperatively.

Correct Answer: 1 Rationale 1: Toddlers, although they will play "side by side" with another child, will not interact with the child during play.

Rationale 2: Preschoolers play cooperatively with other children. Toddlers do not play cooperatively.

Rationale 3: Toddlers do not play house or imitate the adult roles.

Rationale 4: Only preschoolers play cooperatively with other children.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-4 Question 9 Type: MCSA 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 height and weight are disproportionate, and the toddler needs further evaluation.

3. The toddler needs to eat more at each feeding.

4. The family most likely is short.

Correct Answer: 2 Rationale 1: The height and weight for the child described in this question are a concern, and the child might need further endocrine testing.

Rationale 2: 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.

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Rationale 3: The concern is that the weight is out of proportion to the height. Further evaluation is needed.

Rationale 4: The family might be short, but a difference this great between height and weight needs to be referred for further evaluation and testing.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-6 Question 10 Type: MCMA The nurse is teaching a group of mothers of toddlers and preschoolers about oral care and the prevention of caries.

Which statements should the nurse include in the presentation?

Standard Text: Select all that apply.

1. “The tendency toward dental caries is inherited.”

2. “Fruit juice is an excellent source of vitamin C, so allow your child to drink as much fruit juice a day as desired.”

3. “If your child is under two, you should use toothpaste without fluoride.”

4. “Three-year-old children are mature enough to be able to brush their teeth independently.”

5. “The child should see a dentist by one year of age.”

Correct Answer: 3,5 Rationale 1: Poor oral care may be passed from parent to child, but dental caries are not inherited.

Rationale 2: Fruit juice is high in sugar and may promote cavities. The amount of juice per day should be limited.

Rationale 3: A young child may be unable to spit out the toothpaste and will swallow it. To avoid children ingesting too much fluoride, parents should use toothpaste without fluoride.

Rationale 4: The three-year-old child is not mature enough to brush independently. Although the child should be allowed to attempt to brush, the parent should ensure the teeth are adequately cleaned.

Rationale 5: Early attention to dental health improves the condition of the primary teeth.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-5 Question 11 Type: MCSA The home health nurse is observing the home environment for safety issues to discuss with the mother. Which observation creates a risk of injury for the toddler?

1. The mother fills the mop bucket and places it on the floor. She then leaves the room to obtain the mop.

2. When cooking, the mother only uses the back burners of the stove.

3. The mother straps her child into the high chair.

4. The mother has child-proof latches only on the cabinets containing household chemicals, medications, and poisons.

Correct Answer: 1 Rationale 1: Children can drown in 6 inches of water or less. A curious toddler may fall into the bucket and not have the dexterity to get out and drown.

Rationale 2: This is a safe practice as toddlers can reach up and pull pans off the stove or reach up and touch a hot burner.

Rationale 3: Toddlers like to climb and can be very quick. By strapping the child into the chair, the mother is reducing the risk of a fall.

Rationale 4: This is a convenience issue for the mother. If the cabinet does not contain any danger to the child, the doors do not need to be child-proof.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-5 Question 12 Type: MCMA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The pediatric clinic is scheduled to be remodeled. The charge nurse has been asked to design the new well-child waiting area. In planning the area, the nurse will want to include: Standard Text: Select all that apply.

1. Subdued colors to help calm the children.

2. A separate area where parents can sit and not be disturbed by the children’s noise.

3. Avoiding carpet and draperies which cannot be readily cleaned.

4. Coloring books, crayons, and story books that are stored on a low shelf for easy child access.

5. All wall decorations securely fastened to the walls.

Correct Answer: 3,4,5 Rationale 1: Bright colors would be a better choice to interest and engage the children.

Rationale 2: Parents need to be in the same area to monitor their children’s activity and maintain a safe environment.

Rationale 3: All surfaces should be easily cleaned to remove micro-organisms.

Rationale 4: Activities to distract the waiting children should be readily available.

Rationale 5: This will prevent the child from pulling objects down on themselves.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11-5 Question 13 Type: MCSA During a well-child visit, the nurse questions the mother about a toddler’s food habits. The mother expresses concern that her child, who used to be a good eater and would eat all types of vegetables, now refuses all but three types of vegetables. Which is the appropriate response for the nurse to make to the mother?

1. “This is a serious concern, and we need to address this with the physician.”

2. “Toddlers often go on food jags. Just continue to offer all types of vegetables without making it an issue.”

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3. “Don’t make an issue over it. Just stop offering those favorite vegetables and the child will start eating other vegetables.”

4. “Have you thought about adding a multivitamin to the child’s daily routine?”

Correct Answer: 2 Rationale 1: Food jags are common in this age group.

Rationale 2: Food jags come and go. Unless the avoidance becomes extreme, it does not present a major problem.

Rationale 3: A variety of vegetables should be offered including the favorite ones.

Rationale 4: While a multivitamin is often a good idea during the toddler period, this statement does not address the mother’s concern about the food jags.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6 Question 14 Type: MCMA The mother of an 18–month-old expresses concern that her toddler is having temper tantrums when things don’t go her way. What advice should the nurse offer the mother?

Standard Text: Select all that apply.

1. “This is common in the toddler and represents a loss of self-control.”

2. “Remove the child from the area where the tantrum occurs.”

3. “Provide a distraction for the child without giving in to the child’s desire.”

4. “Remain calm while handling the child and do not raise your voice to the child.”

5. “If the tantrum continues for more than a few minutes, the mother should tap the child lightly on the behind to remind the child the consequences of misbehavior.”

Correct Answer: 1,2,3,4 Rationale 1: This statement is accurate and reassures the mother that the behavior is a common age variation.

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Rationale 2: The goal is to allow the toddler to regain control without a loss of self-esteem. Removing the child from the area will help the child to regain control.

Rationale 3: This is another activity to help the child regain control without a loss of self-esteem. By not giving in to the child’s wishes, the child is not learning to use temper tantrums to get her way.

Rationale 4: This will provide a calming atmosphere that will help the child to regain control.

Rationale 5: It is not a good idea to recommend spanking to any parent. Spanking is counterproductive in helping the child regain control.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6 Question 15 Type: MCSA The mother of a toddler asks the nurse: “Now that my child has outgrown his infant car seat, what should I do when we are in the car?” Which is the best response by the nurse?

1. “Place him in a booster chair on the seat beside you so you can watch him.”

2. “Be sure to select a car seat according to his weight and height, and make sure it contains shoulder harnesses.”

3. “Your child should remain in the rear-facing car seat until he reaches 40 pounds.”

4. “The child can now be buckled safely into the regular car seat belts.”

Correct Answer: 2 Rationale 1: The safest place for the child is in the back seat.

Rationale 2: This is correct information.

Rationale 3: This is incorrect. The rear-facing car seats usually have a weight limit of 20 pounds, after which the child is turned forward.

Rationale 4: This is incorrect information. Young children are better protected in a child car seat with harness straps.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6

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Ball, Child Health Nursing, 3/E Chapter 12 Question 1 Type: MCSA A nurse observes the parent-child interaction during the six-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. Addressing the child, the nurse says, "Are you unhappy when Mommy talks to you like this?"

2. "I am going to refer you for counseling, because your interactions with your child seem so negative."

3. "Perhaps you should leave the room so that I can speak with your child privately."

4. "Let's talk privately. Let's discuss ways you can speak to your child in a positive tone.”

Correct Answer: 4 Rationale 1: The nurse should not ask the child if she is "unhappy" with the parent.

Rationale 2: It is not appropriate to refer them to counseling without a discussion with the parent.

Rationale 3: Because the child is only six years old, it would be difficult to ask the parent to leave the room. If the nurse wants to speak with the child alone, the nurse perhaps would escort the child to another area and speak briefly with the child.

Rationale 4: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, because the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-4 Question 2 Type: MCSA Which of these aspects of developmental health supervision should be included in each health care visit of young children?

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1. Discussions of discipline with the parents 2. Toilet training guidelines 3. Referrals to community agencies 4. Patient and family education Correct Answer: 4 Rationale 1: Discipline, while important to the care of children, is age-specific and not part of the main developmental plan.

Rationale 2: Toilet training is age-specific and does not need to be part of developmental health visits.

Rationale 3: Although referrals to community agencies may be a component of some health care visits, they should not be included in every visit.

Rationale 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-1 Question 3 Type: MCSA 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. Fluoridated water 2. Sorbet and yogurt 3. Peanuts and peanut butter crackers 4. Gummy bears and licorice Correct Answer: 4 Rationale 1: Fluoridated water has been shown to decrease the incidence of dental caries.

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Rationale 2: Foods such as sorbet and yogurt do not stick to the teeth and are not considered foods that increase dental caries.

Rationale 3: Foods such as peanut butter and peanut butter crackers are good sources of nutrients and not associated with increased dental caries.

Rationale 4: Items such as gummy bears and licorice stick to the teeth and lead to dental caries.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-2 Question 4 Type: MCSA A nine-year-old child who has been followed in the same pediatric health care home since birth has come in 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 obese and needs dietary counseling.

2. The child is beginning a growth spurt.

3. As soon as the child begins the adolescent growth spurt, the height and weight measurements will normalize.

4. The parents are most likely below the 50th percentile for height and weight.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: This is not a growth spurt, since height is what is referred to by the term growth spurt.

Rationale 3: The statement about the adolescent growth spurt is incorrect for this age child.

Rationale 4: No assumptions about the parents can be made from the data presented.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12-2 Question 5 Type: MCSA 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. "Tell them 'no,' don't do it again, and don't tell anyone."

2. "Smoking occasionally will not hurt you."

3. Show the child a model of lungs with smoke damage then have the child try to breathe through a straw.

4. Explain to the child the risks associated with smoking.

Correct Answer: 3 Rationale 1: The school-age child wants to be like his peers and won't just tell friends “no” without a justification.

Rationale 2: Smoking occasionally will hurt the child's health, so this response is inappropriate.

Rationale 3: 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.

Rationale 4: A school-age child will not remember or really care about hearing the risks of smoking.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-7 Question 6 Type: MCSA A six-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 about the child’s oral care?

1. Use of teeth whitener Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Use of fluoride 3. Use of mouthwash 4. How many teeth have been lost Correct Answer: 2 Rationale 1: Teeth whitener is not mentioned in the scenario, and while the nurse would be concerned if a sixyear-old was using it, fluoride use is more important.

Rationale 2: 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.

Rationale 3: Mouthwash use in a six-year-old is not as important as asking about fluoride use.

Rationale 4: Asking about the number of teeth lost is not as important as finding out whether fluoride is in use.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-3 Question 7 Type: MCSA 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 go to bed at night?"

3. "What do you know about children who sleepwalk?"

4. "Is the child experiencing any stress at home?"

Correct Answer: 4 Rationale 1: The nurse is more concerned about the reason the child is sleepwalking, not about the amount of sleep the child is getting.

Rationale 2: The nurse is concerned about the reason the child is sleepwalking, not about the child's nighttime routine.

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Rationale 3: 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.

Rationale 4: Sleepwalking and sleep talking sometime occur in school-age children, but they 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-3 Question 8 Type: MCSA While teaching the parent of school-age children about self-esteem, the nurse instructs the parents to: 1. Limit the amount of compliments given to the child.

2. Point out the child’s deficiencies in a nice way while providing suggestions for improvement.

3. Establish the goals they want the child to achieve at a predetermined time.

4. Build on the child's strengths and talents.

Correct Answer: 4 Rationale 1: Complimenting a child's strengths is important to increase self-esteem.

Rationale 2: In trying to build self-esteem in a child, it is important to talk about the child's abilities.

Rationale 3: Setting goals for the child to reach at a selected time could lead to disappointment if they are not reached on time. This will result in a drop in self-esteem.

Rationale 4: 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 will increase the child's self-esteem.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 9 Type: MCSA While teaching the parents of a school-age child about coping with divorce, the nurse instructs the parents to: 1. Explain to the child why their marriage fell apart, being sure to identify each partner’s role in the divorce.

2. Be sure the child understands the divorce is not the child's fault.

3. Spend less time with the child so he doesn't feel the tension between the parents.

4. Allow the child to stay with only one parent until the divorce becomes final.

Correct Answer: 2 Rationale 1: It is not appropriate for the parents to discuss marital concerns with the child.

Rationale 2: 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.

Rationale 3: The parents should spend more time with the child, not less, when experiencing a divorce.

Rationale 4: Staying with only one parent will alienate the child from the opposite parent and is not an appropriate instruction.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-5 Question 10 Type: MCSA 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. "Can you try allowing this to continue but only every other day?"

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3. "I think you must not be good role models, so let's talk about your eating habits."

4. "Let's talk about what types of food are consumed when your child chooses."

Correct Answer: 4 Rationale 1: The child will never eat properly if the parents do not teach this behavior.

Rationale 2: Eating only the food the child wants, even every other day, does not teach appropriate and healthy food habits.

Rationale 3: Stating that the parents are not good role models will only make the parents defensive, and therefore it is inappropriate.

Rationale 4: Seeking to find a more positive way of influencing the eating behavior in this age group is most appropriate.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-2 Question 11 Type: MCSA The school health nurse is evaluating the home environments of several children as they relate to child safety.

Which of these activities places a child at greatest risk for bodily harm?

1. The parents consume alcohol on a daily basis.

2. The child is permitted to participate, unsupervised, in target practice with a revolver.

3. The child is a latchkey child.

4. The parents are in a methadone program.

Correct Answer: 2 Rationale 1: Inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms carries the greatest risk.

Rationale 2: Of all the activities mentioned, playing with guns is the greatest risk for injury.

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Rationale 3: A latchkey child needs special attention, but in the current situation, unsupervised gun use is the greatest risk.

Rationale 4: Inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms carries the greatest risk.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3 Question 12 Type: MCSA 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. Gymnastics 2. Swimming 3. Skateboarding 4. Basketball Correct Answer: 3 Rationale 1: Like all sports, gymnastics requires safety precautions, but it does not require personal protective equipment.

Rationale 2: All children should know how to swim, but personal protective equipment is not required to participate in swimming.

Rationale 3: Skateboarding is considered a contact sport, so it requires use of personal protective equipment, including a helmet, gloves, and elbow and knee pads.

Rationale 4: Basketball is not considered a contact sport. No personal protective equipment is required.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-5 Question 13 Type: MCSA The nurse asks the parent during a clinic visit about the nutritional intake of her eight-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 information about healthy meals and snacks that are easy for school-age children and teens to prepare.

2. Provide a meal plan for the mother to take to her daughter.

3. Provide sample recipes for the mother.

4. Provide coupons for the mother when going to the grocery store.

Correct Answer: 1 Rationale 1: Provide information about healthy snacks to keep at home, ways to improve calcium intake, and the importance of getting at least five fruit/vegetable servings daily.

Rationale 2: Providing a meal plan is not going to help ensure that the child has healthy meals.

Rationale 3: Sample recipes will not help the mother ensure that her child has healthy meals.

Rationale 4: Coupons will not help the mother ensure that healthy foods are available for her child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-7 Question 14 Type: MCSA The nurse and a young mother are discussing ways to best prepare children for starting school. What would be the best suggestion for the nurse to make?

1. Teach the child the alphabet and how to count.

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2. Encourage the mother to tell the child how much she will miss the child while the child is at school.

3. Help the child relate to other adults and separate from the mother by planning play dates and short stays with sitters.

4. Plan for an older child to accompany the child and introduce the child to the teacher on the first day of school.

Correct Answer: 3 Rationale 1: These are skills the child will learn in school. The nurse is more concerned about psychological preparation for starting school.

Rationale 2: By telling the child how lonely she will be while the child is at school, the mother will make the child feel guilty about “abandoning” her.

Rationale 3: The ability to separate from the mother is key to an easy transition to school.

Rationale 4: An older child is not the person to accompany the child. It is appropriate to visit the classroom and meet the teacher prior to the first day of school.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-6 Question 15 Type: MCSA The teacher reports to the nurse that despite adequate intelligence, a child is not performing well in school. The nurse’s initial assessments would include: 1. Talking with the child to determine if there are family stressors, such as divorce, that are interfering with the child’s performance.

2. Conducting a vision and hearing screening.

3. Determining if there is conflict between the child and the teacher.

4. Observing the child in the classroom to see interactions between the child and others.

Correct Answer: 2 Rationale 1: Although this can be a contributor to poor school performance, this is not the initial assessment.

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Rationale 2: Vision and hearing difficulties should be ruled out before other causes are investigated.

Rationale 3: This would not be the initial consideration but would be evaluated later if other causes could not be found.

Rationale 4: This can be beneficial in determining school issues but is not the initial assessment.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-3 Question 16 Type: MCSA A six-year-old child is being seen in the clinic for a well-child visit. The child is visibly nervous and fearful of the nurse and the nurse’s actions. The nurse should: 1. Ask the parent to leave the examination room as this is probably the cause of the child’s nervousness.

2. Assure the child that you will not hurt her.

3. Say to the child: “Tell me why you are so nervous.”

4. Explain to the child what you are doing in terms the child can understand. Explain the equipment and, when possible, let the child handle the equipment first.

Correct Answer: 4 Rationale 1: The six-year-old child usually is most comfortable when the parent remains in the examination room.

Rationale 2: This is a promise the nurse may not be able to keep. Lab tests and immunizations may be a part of the health visit.

Rationale 3: Explaining feelings and why they are present can be very difficult for adults as well as children.

Small children will have even more difficulty in expressing their feelings.

Rationale 4: This activity will help allay the child’s fears.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-5 Question 17 Type: MCMA During a summer healthy child visit, the mother tells the nurse that when school starts, she will be going back to work. The mother expresses her concern that her child will be a “latchkey” kid. Which suggestions will the nurse make to help maintain the child’s safety and comfort?

Standard Text: Select all that apply.

1. “During the summer, leave the child home alone for short periods of time.”

2. “Ensure that an adult will always be available by phone.”

3. “Allow the child’s close friend to stay with the child so that he will not be alone.”

4. “Plan some activities that can serve as distractions for the child while alone.”

5. “Ensure that the child knows how and when to call 911.”

Correct Answer: 1,2,4,5 Rationale 1: This is appropriate to give the child time to become accustomed to being alone in the home.

Rationale 2: This provides back-up for the child should a situation arise that the child cannot handle Rationale 3: Because there is no adult present, it is not a good idea to have another child present in the home.

Rationale 4: This will keep the child busy with safe activities and reduce the attraction of unsafe activities.

Rationale 5: Children must know not only how to call 911 but also when it is appropriate to call.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-6 Question 18 Type: MCMA

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An 11-year-old child tells the nurse that she is having trouble falling asleep at night. What recommendations will the nurse make?

Standard Text: Select all that apply.

1.

“Drink a cup of warm tea at nighttime to induce sleep.”

2. “Try to follow a nighttime routine.”

3. “Avoid sleeping late in the morning or taking a nap.”

4. “Exercise 30 minutes before bedtime to tire the body out.”

5. “Darken the room at bedtime.”

Correct Answer: 2,5 Rationale 1: Tea contains caffeine and should be avoided at bedtime.

Rationale 2: A nighttime routine warns the body that bedtime is approaching and will help the body prepare to rest.

Rationale 3: When you can’t sleep at night, the tendency is to sleep until noon the next day or take a nap in the afternoon. Both activities will inhibit sleep the following night.

Rationale 4: Exercising immediately before going to bed will stimulate the body and keep the child awake.

Rationale 5: Light in the room can interfere with a deep sleep.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-6 Question 19 Type: MCSA The teacher has referred a 10-year-old boy to the school nurse. The school nurse knows that the child is an only child with a single mother who works full time and is going to school. Which additional finding would the nurse identify as putting the child at risk for mental health issues?

1. The child is well nourished, wears glasses, and wears clothing styles that matches the other boys in his class.

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2. The boy has a grandmother, aunts, and several cousins living nearby.

3. The family attends church on a regular basis.

4. The child is not involved in community social activities and does not play sports. The child states he plays video games at home after school.

Correct Answer: 4 Rationale 1: These findings indicate no risk factors and are normal for the age.

Rationale 2: This finding indicates the family is probably not isolated and has social support.

Rationale 3: This finding indicates spiritual support.

Rationale 4: This finding indicates the possibility of social isolation and leads the nurse to gather more data.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3 Question 20 Type: MCSA During a well-child visit, the mother tells the nurse that her 11-year-old child is having problems controlling his temper. The mother states that when he gets mad, he often destroys things including his own possessions. The child recently smashed his bicycle, and the mother wonders how she should handle him. The nurse would suggest: 1. Spanking him when he displays this behavior because he knows better.

2. Not replacing the bike and explaining to him that when he breaks something, it will not be replaced.

3. When the child gets angry, the mother will need to yell at the child in order for the child to hear her response.

4. Discussing the child’s behavior with the pediatrician so that the child can be placed on mood-altering medications.

Correct Answer: 2 Rationale 1: Spanking often makes the child angrier and does not teach the child acceptable behavior.

Rationale 2: This illustrates the natural consequence of his behavior.

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Rationale 3: This will only accelerate the child’s anger.

Rationale 4: The child needs to learn to control his anger instead of controlling his anger through the use of medications.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-7 Question 21 Type: SEQ As children grow and develop, their interests and activities change. Place the following childhood activities in order from interests of a 5-year-old to interests of a 12-year-old.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Hass-defined hobbies such as model building, building with wood, needlepoint Choice 2. Colors in coloring book, mostly staying inside the lines Choice 3. Learns to ride a two-wheel bicycle without training wheels; reads first readers Choice 4. Belongs to the basketball team or cheerleading squad at school Correct Answer: 2,3,1,4 Rationale 1: These activities require skill and coordination, more advanced skills common among the 9- to 10year-olds.

Rationale 2: This is the earliest skill and common to the five-year-old child.

Rationale 3: This is common in children around six to eight years old.

Rationale 4: Schools do not have organized sporting teams until middle school.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 12-1 Question 22 Type: MCSA The nurse in the well-child clinic is concerned with injury prevention and includes topics appropriate to the age and behaviors of the child. Which injury prevention topics would be appropriate to prevent hearing loss?

1. The five-year-old child should wear ear plugs when swimming to prevent otitis media.

2. The 12-year-old child should restrict noise levels when listening to music through earphones.

3. The bike helmet for a seven-year-old should be carefully fitted to prevent damage to the ear canal.

4. The nine-year-old child should avoid sports activities that involve cheering crowds to prevent hearing loss.

Correct Answer: 2 Rationale 1: Ear plugs are not considered necessary unless the child has myringotomy tubes.

Rationale 2: Preteens like to listen to loud music, which can damage the hearing.

Rationale 3: A poorly fitting helmet would be uncomfortable and the child would not wear it, but it is not related to hearing loss.

Rationale 4: The noise level at sporting events would not be of sufficient level or duration to damage hearing.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-7

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Ball, Child Health Nursing, 3/E Chapter 13 Question 1 Type: MCSA An adolescent is being seen in the clinic to discuss health promotion behaviors. The nurse develops and implements a health promotion plan. What will the nurse include in the evaluation of the plan?

1. The effectiveness of the health promotion plan and methods to expand and sustain successful approaches 2. Instruction on what is considered healthy behavior 3. Advice to the adolescent that promoting health behaviors will maintain a healthy lifestyle 4. Information on the adolescent’s attitude toward health 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.

Rationale 2: Instruction on healthy behaviors would be included in the implementation phase of the plan.

Rationale 3: Advising why promoting healthy behaviors is important is part of the implementation phase of the plan.

Rationale 4: Including the adolescent's attitude toward health has little to do with evaluating the success of the plan.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13-1 Question 2 Type: MCSA The nurse is preparing to see an adolescent patient to assess his relationships with others. What should the nurse do when conducting this assessment?

1. Let the parents know the nurse will share the information with them after the exam.

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2. Provide separate time to communicate with both the adolescent and the parents.

3. Avoid asking the parents their opinions of the adolescent's friends.

4. Tell the parents they are not allowed to come into the examination room.

Correct Answer: 2 Rationale 1: The nurse cannot share the information about the exam, as this is a breach of patient confidentiality.

Rationale 2: Provide time alone with both the adolescent and the parents so that everyone has time to talk freely and ask questions.

Rationale 3: The nurse should include the parents' opinions of their child's friends.

Rationale 4: The nurse cannot keep the parents out of the examination room, especially if the adolescent wants the parents there.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-3 Question 3 Type: MCSA An adolescent is visiting the clinic for the first time. What should the nurse keep in mind when attending to this patient?

1. The nurse should explain procedures and introduce personnel to adolescents.

2. Adolescents usually are quiet and will offer no opinions.

3. The nurse should attend to and discharge adolescents quickly.

4. Adolescents are comfortable with their surroundings.

Correct Answer: 1 Rationale 1: If the setting is new to the adolescent, explain the procedures and introduce personnel so the adolescent feels more at ease.

Rationale 2: Adolescents usually will offer their opinions readily.

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Rationale 3: It is important that adolescents feel welcome, important, and unrushed, in order to gain their trust.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-1 Question 4 Type: MCSA An adolescent comes to the clinic because of a concern with a skin lesion, and he 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. Instruct the parent to stay in the waiting room and tell him that the adolescent will give him a report on the exam.

2. Tell the parent he cannot come into the exam room with the adolescent.

3. Reassure the parent that you will talk with him about any of his concerns and questions.

4. Allow the parent to come into the exam room with the adolescent.

Correct Answer: 3 Rationale 1: The adolescent makes the decision about the parent's presence and whether to report the exam to the parent.

Rationale 2: The adolescent decides when the parent comes into the room.

Rationale 3: If a parent comes with the adolescent, be alert that you might need to provide some private time by asking the parent to wait outside for a moment. Reassure the parent that you will talk with him about any of his concerns and questions, and provide him with an opportunity to ask questions and get information as well.

Rationale 4: The adolescent chooses when the parent comes into the room.

Global Rationale: Cognitive Level: Analyzing Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-1 Question 5 Type: MCSA 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. A time to discuss exercise and sports participation.

2. A health supervision opportunity.

3. An opportunity to discuss birth control measures.

4. A chance to discuss the importance of pursuing postsecondary education.

Correct Answer: 2 Rationale 1: Discussing the importance of exercise and sports is important and should be included in overall health supervision.

Rationale 2: All visits should be used as health promotion and health supervision opportunities.

Rationale 3: While discussing birth control measures is important, it is only a small portion of the health supervision requirements.

Rationale 4: Discussing future educational plans is important, but these can be included in the overall health supervision protocols.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-6 Question 6 Type: MCSA 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: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Obtain a nutritional history for each of these adolescents.

2. Refer these adolescents to the school psychologist.

3. Call the respective parents to discuss the eating patterns of each adolescent.

4. Speak with the girls in a group to discuss the problems associated with anorexia nervosa.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: Referring the adolescents to a school psychologist without performing a complete nursing assessment is not appropriate.

Rationale 3: Speaking with the parents would not be appropriate at this time.

Rationale 4: Discussing anorexia nervosa at this point is too extreme.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-2 Question 7 Type: MCSA The nurse is assessing a 15-year-old female. The girl's menses began when she was 12 years old. The girl’s body mass index (BMI) is 27.5 and her height is 5 feet, 2 inches. She weighs 160 pounds. Her school performance has been spotty. The priority client teaching would be related to: 1. Menstrual cycle.

2. Nutritional intake.

3. School performance.

4. Adolescent mini mental health status examination.

Correct Answer: 2 Rationale 1: The menstrual cycle appears to have started at a normal time, and so it is not the priority.

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Rationale 2: 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.

Rationale 3: School performance is not as high a priority as the BMI. Rationale 4: The mental health screening exam is not as high a priority as the BMI. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-2 Question 8 Type: MCSA 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 performance 2. Cigarette smoking 3. School friends 4. Seatbelt use Correct Answer: 2 Rationale 1: The nurse can ask general questions about seatbelt use, academic performance, and school friends without breaching confidentiality.

Rationale 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.

Rationale 3: The nurse can ask general questions about seatbelt use, academic performance, and school friends without breaching confidentiality.

Rationale 4: The nurse can ask general questions about seatbelt use, academic performance, and school friends without breaching confidentiality.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-5 Question 9 Type: MCSA 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. The adolescent's role in the family 2. Teen job responsibilities 3. Possible domestic violence 4. Activities done as a family Correct Answer: 3 Rationale 1: The adolescent's role in the family is not confidential and could be discussed when the parents are present.

Rationale 2: Job responsibilities are not confidential and could be discussed in front of the parents.

Rationale 3: If domestic violence is suspected, it would be appropriate to ask these questions only when the teenager is alone with the nurse or healthcare provider.

Rationale 4: The activities of the family are not confidential and could be discussed when the parents are present.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-5 Question 10 Type: MCSA An obese adolescent who adamantly denies sexual activity has a positive pregnancy test. Which statements would be most appropriate for the nurse to make to this adolescent?

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1. "When was your last menstrual period (LMP)?"

2. "Tell me how you feel about your body image."

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: Asking about the LMP does not help connect the adolescent's past behavior to her pregnancy.

Rationale 2: The adolescent's body image does not address the teen's current situation.

Rationale 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.

Rationale 4: This option is too confrontational and may alienate the adolescent.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-4 Question 11 Type: MCSA 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. "Setting specific alarms and then reinforce the value of being 'on-time' may be helpful strategies to assist her to be more of an 'on-time' individual."

2. "Just let it go for now. Teachers and, in the future, employers will be the best people to help her be 'on-time'."

3. "You need to establish specific time frames for your adolescent and be certain she adheres to them."

4. "You have a major problem. There must be a lot of screaming in your home."

Correct Answer: 1 Rationale 1: The best response is to help the mother find a way to help the teen deal with the problem of lateness.

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Rationale 2: 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.

Rationale 3: The nurse who tells the mother to establish time frames is making the assumption this is not already the case in the household.

Rationale 4: This answer choice makes assumptions about the household communication in which the parent and adolescent live.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-7 Question 12 Type: MCSA 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. Respiratory rate 2. Hepatitis B profile 3. Chest X-ray 4. Scoliosis Correct Answer: 4 Rationale 1: A respiratory rate is not a screening exam for all adolescents. It is done throughout childhood at each health supervision visit.

Rationale 2: The hepatitis B profile is needed only once, prior to administration of the hepatitis B vaccine; however, this is not a required screening for all adolescents.

Rationale 3: A chest X-ray is not a routine screening test for adolescents.

Rationale 4: Routine screening for adolescents includes checking for scoliosis, height, weight, and blood pressure measurements.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-2 Question 13 Type: MCSA 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 takes priority when speaking with the adolescent?

1. Stressing the importance of remaining in a close parent-child relationship during these stressful times 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. Helping the adolescent realize the value of postsecondary education Correct Answer: 2 Rationale 1: The parent-child relationship should not be used as a substitute for the development of new peer relationships.

Rationale 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.

Rationale 3: It would be more upsetting to the adolescent if the nurse made this comment.

Rationale 4: It would not be appropriate to discuss the importance of a college education at this time because the adolescent must deal with the loss of friends and with developing new friends first.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-7 Question 14 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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, the nurse must: 1. Offer personal opinions on the topic and cite examples of what can happen if they don't listen.

2. Allow for discussion, and bring peers who have had experience related to the topic being discussed.

3. Lecture on the topic for the allotted time without any discussion.

4. Discuss sex education related to religious belief.

Correct Answer: 2 Rationale 1: Personal opinions will not carry much weight with a group of adolescents.

Rationale 2: 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 interventions. Appropriate interventions include applying 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.

Rationale 3: Lecturing without discussion will not draw in the adolescent to the content.

Rationale 4: Discussing sex education from a religious viewpoint is not appropriate.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-5 Question 15 Type: MCSA What would be the best way for the nurse to teach adolescents regarding health promotion and health maintenance?

1. Contact the parents and ask what issues they have with their adolescents.

2. Have the adolescents identify a personal health goal.

3. Ask the advice of the counselors at school.

4. Tell the adolescents what you will include in the lecture.

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Correct Answer: 2 Rationale 1: Talking to the parents first is not necessary. Common issues that arise for adolescents should be discussed in general and not according to specific individuals.

Rationale 2: 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.

Rationale 3: It is not necessary for the nurse to ask the counselors at school for advice on health topics.

Rationale 4: Lecturing an adolescent group is not as effective as having an honest and open discussion with adequate time for questions.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-7 Question 16 Type: MCMA While completing the health history of a 15-year-old girl, the nurse learns that the girl is sexually active. Based on this finding, the nurse will screen for which conditions?

Standard Text: Select all that apply.

1. Herpes simplex virus 2. Gonorrhea 3. Chlamydia 4. Impetigo 5. Mononucleosis Correct Answer: 1,2,3 Rationale 1: Herpes simplex 1 and 2 can be sexually transmitted and should be included in the screening.

Rationale 2: Some individuals with gonorrhea may display no symptoms. Because it is a sexually transmitted infection, screening for it would be appropriate.

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Rationale 3: Chlamydia is the most common sexually transmitted infection in the United States. Screening is appropriate.

Rationale 4: Impetigo is a skin infection caused by staphylococcus or streptococcus; it is not a sexually transmitted infection.

Rationale 5: Although mononucleosis is sometimes called “the kissing disease,” it is not considered a sexually transmitted infection. Sexual intercourse is not required for transmission.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-4 Question 17 Type: MCSA The school nurse is performing health screenings during the physical education class. The nurse plans to weigh, measure, and determine body mass index of the adolescents. The scale has been set up in the open gym to speed the process. What should the nurse do to maintain confidentiality of the findings?

1. Have a student worker record the screening findings on the appropriate adolescent’s record.

2. Have a volunteer weigh and measure the adolescents and verbally give the findings to the nurse to calculate the body mass index and record.

3. Provide a privacy screen and have the health aid record the findings directly on the record. The nurse will then calculate body mass index.

4. Use a buddy system with the students, having the students measure each other and record the findings.

Correct Answer: 3 Rationale 1: This would be inappropriate. Other students should not have access to any adolescent’s private information.

Rationale 2: Volunteers should not be included in the process of gathering data. Verbal reporting of findings would allow other adolescents to hear the results, violating the confidentiality of the student being screened.

Rationale 3: A privacy screen and written responses will prevent other adolescents for hearing or seeing results.

Rationale 4: Although this limits the number of adolescents who have access to personal data, this still is an invasion of privacy.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-3 Question 18 Type: MCSA Nurses working with adolescents should encourage the adolescents to assume more of the responsibility for their healthy behaviors. To promote this personal responsibility, the nurse will want to provide adolescents with information about which health promotion activities?

1. Self-breast exams for girls and self-testicular exams for the boys 2. Immunizations that need to be updated 3. Communicable diseases that are prevalent in the community 4. The importance of eating together as a family several times a week Correct Answer: 1 Rationale 1: Self-breast/testicular exams are appropriate areas for adolescents to begin assuming health surveillance behaviors.

Rationale 2: While it is appropriate to inform the adolescent of needed immunizations, the nurse will include the parents in sharing this information.

Rationale 3: Knowing what communicable diseases are prevalent will not help the adolescent assume responsibility for health care.

Rationale 4: While this is healthy for the adolescent, it is not an area that the adolescent can control. This topic should be discussed with the adolescent and the parents together.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-6 Question 19 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA The eating disorders clinic sees a number of overweight adolescent girls. In addition to monitoring these adolescents for the health problems related to obesity, the nurse will monitor the girls for which mental health problem?

1. Substance abuse 2. School phobia 3. Spiritual distress 4. Negative self-esteem Correct Answer: 4 Rationale 1: This is not the major mental health issue associated with obesity.

Rationale 2: While the girls may dislike attending school, this is not the mental health problem the nurse should be evaluating.

Rationale 3: Adolescents may have issues related to spirituality, but this is not associated with obesity.

Rationale 4: Self-esteem is tied closely to body image, a common source of distress among obese adolescents.

Therefore, the nurse will monitor the girls for issues with self-esteem.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-2 Question 20 Type: MCMA The school nurse is working with an adolescent who reports that he gets six hours or less of sleep at night. The nurse explains to the adolescent that some of the common consequences of inadequate sleep include: Standard Text: Select all that apply.

1. Hyperactivity.

2. Increased nocturnal emissions.

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3. Increased risk of automobile accidents when driving.

4. Moodiness.

5. Being unable to perform well at school.

Correct Answer: 3,4,5 Rationale 1: Inadequate sleep is more likely to lead to hypoactivity.

Rationale 2: This is a common occurrence of early adolescence and not related to sleep deprivation.

Rationale 3: This is a possibility in the adolescent who is sleep deprived.

Rationale 4: Parents often report that sleep-deprived adolescents tend to be moody and are difficult to communicate with.

Rationale 5: Drowsiness will inhibit the performance of the adolescent.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-1 Question 21 Type: MCMA An adolescent reports that after hearing about all the hazards of cigarette smoking, he has changed to chewing tobacco. The nurse will want to inform that adolescent of the risk factors associated with smokeless tobacco, including: Standard Text: Select all that apply.

1. Lung cancer.

2. Nicotine addiction.

3. Mouth cancers.

4. Emphysema .

5. Mouth ulcers.

Correct Answer: 2,3,5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Smokeless tobacco does not increase the risk of lung cancer.

Rationale 2: Nicotine addiction occurs with chewing tobacco as it does with smoking cigarettes.

Rationale 3: Cancer of the mouth is associated with chewing tobacco.

Rationale 4: Respiratory illnesses are not a common risk factor for smokeless tobacco.

Rationale 5: Mouth ulcers occur in individuals who chew tobacco.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-7 Question 22 Type: MCSA The nurse will want to screen all adolescents for problems associated with the primary developmental task of adolescents. In that area, the nurse will ask questions about: 1. The adolescent’s adaptation to high school.

2. Establishing positive peer relationships.

3. Finding a life career.

4. Developing a healthy lifestyle.

Correct Answer: 2 Rationale 1: Adapting to high school is not the primary psychosocial developmental task of adolescence.

Rationale 2: The primary task for the adolescent is to separate from parents and develop positive peer relationships.

Rationale 3: Adolescents are considering various future occupations, but that is not their primary developmental task.

Rationale 4: Although this is beneficial, it is not the developmental task of adolescence.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-3 Question 23 Type: MCMA While assessing risk factors in adolescents, the nurse recognizes that dental issues may be related to: Standard Text: Select all that apply.

1. Fluoridated water.

2. Failure to use a mouth guard when playing physical sports.

3. Adolescent obesity.

4. Diagnosis of bulimia.

Correct Answer: 2,4 Rationale 1: Fluoride is not needed in the adolescent once all teeth have emerged; this does not constitute a risk factor.

Rationale 2: Injury to teeth can occur, so a mouth guard should be utilized.

Rationale 3: Dental injuries can be related to eating disorders, but the problem would be inadequate, not excessive, nutrition.

Rationale 4: Repeated vomiting can destroy enamel due to contact with acidic stomach juices.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-4 Question 24 Type: MCSA The school nurse recognizes that an adolescent comes from a family with limited financial resources. The nurse is developing a nursing care plan to assist the adolescent with his needs. An appropriate nursing diagnosis would be: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Altered financial support related to inadequate parental support.

2. Imbalanced nutrition: Less than body requirements related to familial financial difficulties.

3. Knowledge deficit related to sources of financial support.

4. Risk for injury related to imbalanced nutrition.

Correct Answer: 2 Rationale 1: Nurses have limited ability to intervene in areas related to finance. This is not a legitimate nursing diagnosis.

Rationale 2: Imbalanced nutrition is a nursing diagnosis and is appropriate.

Rationale 3: Referral to community resources may be necessary, but the diagnosis of imbalance nutrition is more appropriate and comprehensive.

Rationale 4: This is two diagnoses in one. A clearer diagnosis is simply imbalanced nutrition.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13-4 Question 25 Type: MCMA While promoting participation in physical activities at school, the nurse recognizes that factors which may inhibit the adolescent from participating would include: Standard Text: Select all that apply.

1. The family members do not regularly participate in physical activity.

2. The adolescent is overweight.

3. The public school does not have sports programs available.

4. Participating in sports may require financial resources.

5. Physical activities are limited to the best athletes.

Correct Answer: 1,2,4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Children model their behavior after their parents. This is a factor that may inhibit the adolescent.

Rationale 2: An adolescent who is overweight is less likely to join sports teams.

Rationale 3: Public schools offer a variety of sports programs.

Rationale 4: Registration fees and equipment may be required for sports participation.

Rationale 5: While “making the school team” does require a higher level of ability, schools have intramural teams as well as physical education classes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-6

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Ball, Child Health Nursing, 3/E Chapter 14 Question 1 Type: MCSA Prior to accepting an assignment as a home health nurse, the nurse must realize that: 1. The family will adapt their lifestyle to the needs of the nurse.

2. The family is in charge.

3. Independent decisions regarding emergency care of the child will be made by the nurse.

4. All decisions will be made by the healthcare provider.

Correct Answer: 2 Rationale 1: The nurse must be flexible and adaptable to the lifestyle of the family, not the other way around.

Rationale 2: The home health nurse must realize that the family is in charge.

Rationale 3: The family must provide informed consent for emergency care.

Rationale 4: All decisions will be made by the family, not by the healthcare provider.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-2 Question 2 Type: MCMA A majority of pediatric health care occurs in community-based settings. Community-based health care settings include: Standard Text: Select all that apply.

1. The local community hospital.

2. Outpatient surgical facilities.

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3. The public health clinic.

4. An inpatient mental health center.

5. A pediatrician’s office Correct Answer: 2,3,5 Rationale 1: The hospital is not a community-based setting.

Rationale 2: Outpatient day surgery centers are community-based healthcare settings.

Rationale 3: The public health clinic is a community-based healthcare setting.

Rationale 4: An inpatient mental health center is a hospital-based program and is not considered a communitybased program.

Rationale 5: A pediatrician’s office would be a community-based healthcare setting.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-1 Question 3 Type: MCSA A pediatric nurse has accepted a position in a pediatric office. What nursing functions would the nurse expect to perform in this setting?

1. Performing minor surgical procedures 2. Providing medical care to chronically ill children 3. Planning hospital admissions 4. Identifying children in need of urgent care or isolation Correct Answer: 4 Rationale 1: Nurses do not perform minor surgical procedures, regardless of location.

Rationale 2: The nurse would provide nursing care, not medical care, to chronically ill children.

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Rationale 3: Children seen at the clinic who need to be admitted to the hospital will be admitted under the physician’s care. The nurse may transmit medical orders from the physician but is not responsible for planning hospital admissions.

Rationale 4: The nursing process is used when providing care for children who are seen in the pediatrician’s office. Specific functions of the pediatric nurse in this setting include identifying children in need of urgent care or isolation.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-2 Question 4 Type: MCSA 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. Parents' insurance 2. Parents' income 3. Readiness of the home for the child who is returning home from the hospital 4. Parents' home location Correct Answer: 3 Rationale 1: The nurse would not assess the parents’ insurance. Social workers might assist the parents in this area.

Rationale 2: The nurse would not assess the income of the parents. Social workers might assist in this arena.

Rationale 3: 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 in and out of the home).

Rationale 4: The home location is assessed only insofar as determining whether heat, electricity, water, and the necessary services are available in the location.

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Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-2 Question 5 Type: MCSA A 16-year-old client has a long leg cast secondary to a fractured tibia. The child will require a wheelchair for mobility. To effectively facilitate the adolescent's return to school, the school nurse should: 1. Meet with all of the other students prior to the student's return to school to emphasize the special needs of the injured teen.

2. Meet with teachers and administrators at the school to discuss modifications in the student’s school routine.

3. Develop an individualized health plan (IHP) focusing on long-term needs of the adolescent.

4. Meet with parents of the injured student to encourage homebound schooling until a short leg cast is applied.

Correct Answer: 2 Rationale 1: It is not necessary to meet all of the students to discuss the adolescent's needs.

Rationale 2: Plans must be made to modify the school routine for the student. The adolescent will be unable to participate in some classes, such as physical education and some vocational classes.

Rationale 3: While an IHP might be developed, short-term needs would be the focus.

Rationale 4: There is no reason to encourage the child to stay at home for school if he is ready to return.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-2 Question 6 Type: MCSA The community health nurse is planning an education session for recently hired teachers at a childcare center. It is most important that the nurse teach the staff: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. The schedule for immunizations.

2. How to interpret health records.

3. Principles of infection control.

4. How to take a temperature.

Correct Answer: 3 Rationale 1: The schedule of immunizations is important for childcare administrators to know, but it is not most important for teachers to know this information.

Rationale 2: Although it is important for childcare administrators to be able to interpret health records to ensure compliance with state regulations, teachers do not necessarily need to know this information.

Rationale 3: 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.

Rationale 4: It is important for the childcare teacher to know how to take a temperature, but infection control is the priority for discussion.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-2 Question 7 Type: MCSA Prior to her return to school, an individualized health plan (IHP) will be developed for the child who has: 1. Missed two weeks of school due to mononucleosis.

2. Been newly diagnosed with insulin-dependent diabetes mellitus.

3. Recently developed a penicillin allergy.

4. Been treated for head lice.

Correct Answer: 2 Rationale 1: While a child who has missed two weeks of school will need to make arrangements for makeup work, an IHP is not needed.

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Rationale 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.

Rationale 3: 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.

Rationale 4: A child who has been treated for head lice can return to school and does not need an IHP. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-2 Question 8 Type: MCSA A child with a history of asthma presents to the school nurse complaining of wheezing. The nurse assesses the child and notes that the respiratory rate is 36 and expiratory wheezes are heard throughout the lung field. The child’s oxygen saturation is 98%. Which is the best initial action by the nurse?

1. Call the child's parents to come pick up the child.

2. Have the child use his metered-dose inhaler.

3. Call 911 to request emergency medical assistance.

4. Have the child lie down to see if the symptoms subside.

Correct Answer: 2 Rationale 1: Parents may be notified if the child does not feel well, but this is not the initial action.

Rationale 2: 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.

Rationale 3: Emergency personnel should be notified if the inhaler does not provide relief and the child develops respiratory distress.

Rationale 4: Having the child lie down likely will worsen his condition.

Global Rationale:

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Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-2 Question 9 Type: MCSA 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. Advise the parent to hang up and call 911.

2. Reassure the parent and provide instructions on home care for the child.

3. Instruct the parent to make an appointment for the child to see the health care provider.

4. Obtain the history of the illness from the parent.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: Home care is not appropriate, as a crowing sound at rest with a change in the level of consciousness makes this an emergency situation; the nurse should instruct the parent to call 911.

Rationale 3: Making an appointment would be appropriate in non-emergency situations.

Rationale 4: Obtaining the history is appropriate only after the child has received emergency treatment to control the airway.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-2 Question 10 Type: MCSA The number of serious injuries of children in a community has doubled in the past year. Based on this information, the most appropriate nursing diagnosis for the community would be: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Altered Family Processes related to hospitalization of an injured child.

2. Noncompliance related to inappropriate use of child safety seats.

3. Injury, risk for related to inadequate use of bicycle helmets.

4. Knowledge, Deficit injury prevention in children.

Correct Answer: 4 Rationale 1: 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.

Rationale 2: There is insufficient information to identify causes of the injury rates, so assuming non-compliance would be inappropriate.

Rationale 3: There is insufficient information to support this diagnosis.

Rationale 4: Knowledge Deficit is the only diagnosis that is general to the problem as a whole, as there is insufficient information regarding the nature of the injuries and possible causes; this is therefore the most appropriate community nursing diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14-4 Question 11 Type: MCSA A child who is medically fragile is being discharged home after a long hospital stay. The child will require someone to provide medical treatments several times a day. In planning discharge, the nurse will: 1. Train all members of the family to take part in the child's care.

2. Plan for a home health nurse to visit the child four times a day to provide the medical treatment.

3. Determine with the family which family members may be trained to provide care for the child.

4. Evaluate the size of the child's room for therapy.

Correct Answer: 3

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Rationale 1: Training all members to participate in the care of the child might be inappropriate based each member's age, abilities, and developmental stage.

Rationale 2: It is impractical to expect a home health nurse to visit more than once a day. The nurse should determine if family members can be trained to provide the needed care.

Rationale 3: Not all members of the family will be able or willing to provide care. One parent, both parents, or members of the extended family may be the best option for home care.

Rationale 4: The size of the child's room has no bearing on the child's care as given by the family members.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-4 Question 12 Type: MCSA As the new school year begins, the school nurse evaluates several children to determine their healthcare needs.

Which child would the nurse consider to be medically fragile?

1. The child with a casted right arm due to a fracture 2. The child who wears hearing aids due to hearing loss secondary to meningitis as an infant 3. The child requiring oxygen and tube feedings secondary to a congenital heart defect 4. The child with a developmental delay Correct Answer: 3 Rationale 1: This is a temporary issue and does not constitute a significant health issue.

Rationale 2: This is a normal healthy skin with a sensory deficit, not a significant health issue.

Rationale 3: This child has current medical issues which require continued monitoring and care. This child would be considered medically fragile.

Rationale 4: This child may need special support in the classroom but is not considered medically fragile.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-6 Question 13 Type: MCSA An important goal for pediatric nurses in the office or healthcare setting is: 1. Develop a positive relationship with the child and family.

2. Develop a plan of care with the physician for the family.

3. Tell the family immediately what's wrong with the child.

4. Tell the family "Everything will be okay."

Correct Answer: 1 Rationale 1: An important goal for nurses in the office or healthcare 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.

Rationale 2: The nurse does not develop a plan for medical care, with or without the physician.

Rationale 3: The nurse might not be able to tell the family what is wrong with the child.

Rationale 4: This is not therapeutic communication, as the nurse cannot guarantee that "everything will be okay."

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-4 Question 14 Type: MCSA The pediatric nurse works at a camp for children with diabetes. As a component of the job, the camp nurse works: 1. Directly under the supervision of the camp doctor.

2. With standard protocols to guide nursing interventions.

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3. As an emergency medical technician.

4. Only in emergency situations.

Correct Answer: 2 Rationale 1: Camps typically have a medical director who has developed set protocols for nursing care but is not directly involved in the day-to-day care of the children.

Rationale 2: Nurses typically work with set protocols determined by the camp medical director.

Rationale 3: The camp nurse will work as a nurse and provide more care than that available from an EMT. Rationale 4: In addition to emergency interventions, the camp nurse will monitor the day-to-day health of the campers and may provide health education.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-2 Question 15 Type: MCSA A major goal of home health care nurses working with families is: 1. Maximizing the dependency of the child on the family.

2. Curing the chronic illness of the child.

3. Prescribing and administering medication needed by the child.

4. Promoting or restoring the child's health.

Correct Answer: 4 Rationale 1: The home health care nurse encourages children to learn to function as independently as possible.

Rationale 2: The nurse's role in home health care is to provide nursing care for the child, not to cure the child’s chronic illness.

Rationale 3: The nurse might assist in medication administration for the child but would not prescribe the needed medication.

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Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-4 Question 16 Type: MCSA 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. Provision for an alternate heating source if power is lost 2. Notifying the power company that the child is on life support 3. Designation of an emergency shelter site 4. Acquisition of a backup generator Correct Answer: 4 Rationale 1: A secondary heat source is secondary to acquiring alternative power for the ventilator.

Rationale 2: Notifying the power company is secondary to acquiring alternative power for the ventilator.

Rationale 3: 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 14-6 Question 17 Type: MCSA Which aspect of an Emergency Medical Services (EMS) system is most indicative that EMS providers are prepared to provide emergency care to children?

1. Lists of hospitals in the area that treat children 2. Staff education related to assessment and treatment of children of all ages 3. Placement of small stretchers in emergency vehicles 4. Size-appropriate equipment and supplies Correct Answer: 2 Rationale 1: Having lists of hospitals that treat children is important, but providing education for EMS providers is more indicative of preparedness.

Rationale 2: 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 of children.

Rationale 3: The stretcher size would not necessarily change to transport a child; the addition of car seat might be more indicative of preparedness.

Rationale 4: Size-appropriate equipment for children is an essential part of an EMS system, but it is less important than knowing how to use the equipment and assess children.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14-6 Question 18 Type: MCSA Which of the following should be considered in disaster preparedness for children with special needs?

1. Current medical information should be maintained only by the child's health care provider.

2. Only one family member should be trained to provide the needed care for the sake of consistency.

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3. The utility company needs advance notification when a child is technology-assisted to provide emergency power.

4. Minimal supply of medication, equipment, and supplies should be maintained.

Correct Answer: 3 Rationale 1: 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.

Rationale 2: 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.

Rationale 3: Planning is important when a family has a child with a chronic health condition or one who is technology-assisted. The utility company needs advance notification when a child is technology-assisted to provide emergency power as quickly as possible.

Rationale 4: Several days' worth of medications and supplies should be maintained at all times.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-6 Question 19 Type: MCSA The nurse has recommended respite care for the family of a two-year-old child who is medically fragile. The mother asks what respite can do for them. The nurse’s response will be based on the knowledge that: 1. Respite care will admit the child for an evaluation of the child’s medical condition.

2. Respite care gives the family a break from the daily demands of caring for a child who is medically fragile.

3. Respite care can provide support for the child during local disasters.

4. Respite care will admit the child and family to their facility and provide the whole family a vacation experience.

Correct Answer: 2 Rationale 1: The purpose of respite care is not to evaluate the child’s medical condition.

Rationale 2: Respite care includes admission to a facility that will care for the child for a short period of time, allowing family members a chance to recoup their energy and strength.

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Rationale 3: This would not be the purpose of respite care.

Rationale 4: Only the child who is medically fragile would be admitted to the respite unit.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-1 Question 20 Type: MCSA While working in a pediatrician’s office, the nurse frequently steps into the waiting room to speak quickly with the families and children waiting their turn. This allows her the opportunity to observe the children and their families. Based on her observations, which child should the nurse move to the examining room next?

1. The child with a flushed face and rash that is visible on all exposed skin 2. The four–month-old infant who has come for immunizations 3. The child holding his ear and crying 4. The adolescent holding his swollen hand and complaining of pain Correct Answer: 1 Rationale 1: The flushed face could indicate a fever. The rash may be related to a communicable disease. It is important that this child not expose other children, so this child should be moved to the examination room to reduce exposure.

Rationale 2: This child can wait until called to the examining room.

Rationale 3: This child probably has an ear infection and can wait until called to the examining room.

Rationale 4: This child may have a break or a sprain but can wait until called to the examination room.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 21 Type: MCMA The weather report predicts a hurricane may be approaching the area where a child who is medically fragile lives.

As a component of the family’s disaster planning, the nurse will discuss which actions with the family?

Standard Text: Select all that apply.

1. Providing the child’s pediatrician with contact information of a health care provider in the area to which they will evacuate if that becomes necessary 2. Having sufficient medication available for at least one week 3. Having contact information for Emergency Medical Services so that they can transport the medically fragile child to the selected evacuation location 4. Admitting the child to the local hospital prior to the family evacuating the area 5. Riding out the hurricane at home; the child is too fragile to transport Correct Answer: 1,2 Rationale 1: This would be appropriate. There are often several options for evacuation sites, so the parents can plan to reach a specific area.

Rationale 2: It is hard to refill medications when the family has temporarily located at a distance from their home pharmacy.

Rationale 3: The EMS will not be expected to provide transportation to the selected evacuation location. If the child cannot travel by family care, the parents will need to contract an ambulance service for transport.

Rationale 4: The best plan would be for the family to evacuate the child to a safe area. If the hurricane does hit the area, the hospital could be damaged or destroyed.

Rationale 5: Hurricanes can cause widespread damage, including long-term damage to water and electric infrastructures, which are required to care for the child who is medically fragile at home.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-6 Question 22 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCMA The nurse working in a pediatric clinic will have many duties. Included in the nurse’s responsibilities will be: Standard Text: Select all that apply.

1. Prescribing over-the-counter medications.

2. Collecting health history information.

3. Performing diagnostic tests, such as the TB skin test.

4. Performing developmental screening tests.

5. Administering immunizations.

Correct Answer: 2,3,4,5 Rationale 1: This is a medical function. Nurses cannot prescribe any medication, even over-the-counter medications.

Rationale 2: The nurse will begin the visit with an assessment that includes the health history.

Rationale 3: Nurses will perform some diagnostic tests in the office.

Rationale 4: The nurse may perform the Denver Developmental Screening Test.

Rationale 5: Nurses will administer immunizations and other medications prescribed by the physician.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-2 Question 23 Type: MCMA The nurse is applying for a job as a pediatric telephone advisor. Skills the nurse should have to be effective in this position would include: Standard Text: Select all that apply.

1. Good listening skills.

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2. Extensive pediatric experience.

3. Internet experience.

4. Psychiatric experience.

5. Teaching and verbal communication skills Correct Answer: 1,2,5 Rationale 1: Because the nurse will need to assess situations totally by what is said, the nurse must be a good listener.

Rationale 2: The nurse will need to use both assessment and implementation skills to be successful.

Rationale 3: The nurse may want to search for information on the internet, but the majority of information to be shared will be based on protocols provided by the medical directors of the company.

Rationale 4: Although communication will be of prime importance, the nurse will not need to be an experienced psychiatric nurse.

Rationale 5: Because much of the advice given will be how to handle a situation, teaching and communication skills will need to be above average.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-2 Question 24 Type: MCMA A child is being discharged from the hospital on home antibiotic infusions for two more weeks. The intravenous line is in place, and the medication will be delivered by the pharmacy and ready to administer on the infusion pump. The home health nurse will visit once a day, but the family will be responsible for administering the medication. The home health nurse will want to educate the family on: Standard Text: Select all that apply.

1. How to initiate an intravenous line.

2. How to operate the infusion pump.

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3. The side effects of the medication.

4. Actions to take in case of anaphylaxis.

5. Signs of infection.

Correct Answer: 2,3,4 Rationale 1: The parents will not be expected to start an intravenous line. If a replacement is needed, the home health nurse will visit and perform the skill.

Rationale 2: Home infusion pumps are simple and easily learned. The parents will be expected to operate the pump.

Rationale 3: The parents will need to understand potential side effects so that they can recognize changes in the child’s condition.

Rationale 4: Anaphylaxis can occur with any dose. The parents will need to know what to do should it occur.

Rationale 5: The infection has already been diagnosed. The nurse will not need to teach the parents what symptoms might be due to infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-4

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Ball, Child Health Nursing, 3/E Chapter 15 Question 1 Type: MCSA 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. Lies quietly in bed.

2. Does not cry if his parents return and leave again.

3. Appears to be happy and content with staff.

4. Screams and cries when his parents leave.

Correct Answer: 1 Rationale 1: Children in the "despair" stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these.

Rationale 2: 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.

Rationale 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.

Rationale 4: Screaming and crying are components of the "protest" stage.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 2 Type: MCSA In addition to separation anxiety, infants between six and 18 months of age also might display: 1. Fear of disfigurement.

2. Fear of death.

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3. Stranger anxiety.

4. Fear of bodily injury.

Correct Answer: 3 Rationale 1: Infants do not fear disfigurement.

Rationale 2: Infants and toddlers do not fear death.

Rationale 3: In addition to separation anxiety, infants between six and 18 months of age might display stranger anxiety when confronted with strangers such as health care professionals.

Rationale 4: Infants and toddlers do not fear bodily injury.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 3 Type: MCSA The parents of a child who is critically injured wish to stay in the room while the child is receiving emergency care. The nurse should: 1. Ask the physician if the parents can stay with the child.

2. Allow the parents to stay with the child.

3. Escort the parents to the waiting room and assure them that they can see their child soon.

4. Tell the parents that they do not need to stay with the child.

Correct Answer: 2 Rationale 1: The physician does not make the decision whether the parents stay with the child; the parents make the decision.

Rationale 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.

Rationale 3: Parents should be allowed to stay with their child if they wish instead of going to the waiting room where they lack privacy.

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Rationale 4: The parents need to make the decision about staying with their child without input from the nurse.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-4 Question 4 Type: MCSA The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that the hospitalized child who is at greatest risk for experiencing separation anxiety when parents cannot stay is the: 1. Six-month-old.

2. 18-month-old.

3. Four-year-old.

4. Six-year-old.

Correct Answer: 2 Rationale 1: The six-month-old does not experience separation anxiety, which usually begins at around one year of age.

Rationale 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.

Rationale 3: The four-year-old is past the age when separation anxiety would be most prevalent.

Rationale 4: The six-year-old is attending school and is used to short periods of separation from parents.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA A four-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. Yelled at his brother.

3. Did not eat the right foods.

4. Did not take his vitamins.

Correct Answer: 2 Rationale 1: At this age, the child does not yet understand that he can become sick from exposure to someone else who is sick.

Rationale 2: 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.

Rationale 3: Not eating the right foods can be a factor in some illnesses, but this thinking is beyond the level of a four-year-old.

Rationale 4: While not taking his vitamins can be a factor in some illnesses, this thinking is beyond the capabilities of a four-year-old.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 6 Type: MCSA A five-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. Escort the child to his room and ask the child life specialist to bring toys to the bedside.

2. Reschedule the treatment for a later time.

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3. Assist the child back to his room for the treatment but reassure him that he may return when the procedure is completed.

4. Show the respiratory therapist to the playroom so the treatment can be performed.

Correct Answer: 3 Rationale 1: The child should be allowed to return to the playroom as soon as the procedure is completed; bringing toys to the bedside is unnecessary.

Rationale 2: Scheduled respiratory treatments should be performed on time.

Rationale 3: It is important for scheduled treatments to occur on time, so the child should go back to his room. He can return to the playroom as soon as the treatment is completed.

Rationale 4: Procedures should not be performed in the playroom.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5 Question 7 Type: MCSA A five-year-old child is admitted to the pediatric unit for surgery. The parents request to stay with their child.

Which is the best response by the nurse?

1. Tell the parents they can stay in the hospital but not on the unit.

2. Read the rules and regulations of rooming in with the child.

3. Let the parents know they are allowed to stay with the child.

4. Explain to the parents why they cannot stay with the child.

Correct Answer: 3 Rationale 1: The parents should be allowed to stay with their child on the unit.

Rationale 2: The parents should be aware of the rules about rooming in, but they should know first that they can stay.

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Rationale 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.

Rationale 4: The parents should be allowed to stay with their child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-4 Question 8 Type: MCSA A child is being prepared for surgery. The parent requests to be present during anesthesia induction. How should the nurse respond?

1. The nurse should tell the parent the names of all the medications the child will receive.

2. The nurse should explain what the parent will see and hear when present during induction.

3. The nurse should tell the parent he will be upset to see his child under anesthesia.

4. The nurse should ignore the request and focus on the child.

Correct Answer: 2 Rationale 1: The parent does not need to know the names of the medications the child will receive.

Rationale 2: The nurse explains visual and auditory experiences, such as a surgical gown, cap, shoe covers, and the parent's role in presence during induction. The nurse offers the parent an opportunity to ask questions and voice concerns.

Rationale 3: The nurse should tell the parent what to expect but not how he will feel while he watches his child.

Rationale 4: The nurse should never ignore a request made by a parent.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 15-4 Question 9 Type: MCSA 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. Inform the parent she will be asked to leave if she continues this behavior.

2. Apologize for the parent’s perception and assure the parent that the staff will keep her informed. Inform the parent of any change in the child’s condition as soon as possible.

3. Offer to ask the doctor to come and talk with her.

4. Tell the parent her behavior will upset the child.

Correct Answer: 2 Rationale 1: Telling the parent she will be asked to leave will only worsen the situation.

Rationale 2: 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.

Rationale 3: The parent is already angry because of the lack of information sharing. The nurse should not "pass the buck" to the physician.

Rationale 4: The parent is already angry, and informing her that her behavior will upset the child will only anger her more.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-4 Question 10 Type: MCSA 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. Explain to the parents that their anger is affecting their child, and they will not be allowed to visit the child until they calm down.

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2. Ask the physician to talk with the family.

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: Telling the parents that they cannot visit their child will only increase their anger.

Rationale 2: 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.

Rationale 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.

Rationale 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5 Question 11 Type: MCSA The nurse must perform a procedure on a toddler. The technique most appropriate when performing the procedure is to: 1. Allow the child to cry or scream.

2. Perform the procedure in the child's hospital bed.

3. Ask the child if it is okay to start the procedure.

4. Ask the mother to restrain the child during the procedure.

Correct Answer: 1 Rationale 1: The child should be allowed to cry or scream during the procedure.

Rationale 2: The treatment room should be utilized for the procedure so that the hospital bed remains a safe place.

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Rationale 3: The nurse should avoid giving the child a choice if there is no choice.

Rationale 4: While the toddler will need to be restrained, the parent should not be the one to do this.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-5 Question 12 Type: MCSA 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. Tell the patient and family that everything will be fine.

2. Explain to the patient and family how the child will benefit from the surgery.

3. Tell the patient and family that the surgeon is very good.

4. Give a tour of the hospital unit or surgical area.

Correct Answer: 4 Rationale 1: The nurse cannot know for certain that everything will be fine.

Rationale 2: The pros and cons of the surgery would have been explained to the family prior to the decision to have the surgery. Restating the benefits will not reduce the stress of the patient and family.

Rationale 3: 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 15-5 Question 13 Type: MCSA When a parent asks to be present during a procedure, the nurse should understand that: 1. The parent wants to support his child before, during, and immediately after the procedure.

2. The parent wants to ensure that nothing goes wrong with the child.

3. The parent is interested because he is also in the medical field.

4. The parent wants to ensure that the correct medication is being used.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: 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.

Rationale 3: The parent might be in the medical field, but his primary concern is comforting his child during the procedure.

Rationale 4: The parent's first concern is comforting his child, not supervising the nursing staff.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-6 Question 14 Type: MCSA The parents have requested to be present during their child's procedure. How should the nurse plan for this request?

1. Explain in detail, using medical terms, what will occur.

2. Explain to the family that it is not permitted for family members to be present.

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3. Prepare family members for what they should anticipate and what is expected of them.

4. Prepare the family to speak with the physician.

Correct Answer: 3 Rationale 1: The nurse should not use medical terms to discuss the child's procedure.

Rationale 2: In most circumstances, it is not only permitted but desired to have the parents present during a procedure.

Rationale 3: 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.

Rationale 4: The nurse can speak to the family to prepare them and does not need to wait for the physician.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-6 Question 15 Type: MCSA 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. What is the priority nursing diagnosis?

1. Parental anxiety related to care of the child at home 2. Family processes, altered related to hospitalization 3. Infection, risk for related to presence of healing wounds 4. Knowledge deficient home care Correct Answer: 1 Rationale 1: 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.

Rationale 2: The child is being discharged, so this is not the priority diagnosis.

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Rationale 3: The mother has shown appropriate care of the wounds, decreasing the likelihood of infection, so this diagnosis is not the priority.

Rationale 4: The mother has exhibited correct technique, so this is not the priority diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15-7 Question 16 Type: MCSA A child has been hospitalized for an extended time period and is being discharged home. This child requires complex, long-term care and will have a home health nurse visit daily. In addition to a central line, the child is on oxygen by nasal cannula. What should the nurse teach the family members?

1. How to insert an IV line 2. Nothing, the family is familiar with the care.

3. Instruction on oxygen administration 4. How to remove a central line Correct Answer: 3 Rationale 1: Starting an IV line is not within the family's responsibilities for home care.

Rationale 2: The nurse can never assume the family members are familiar with the care required, even if they have been participating during the hospital stay.

Rationale 3: Prior to discharge, the parents will need to learn about oxygen administration.

Rationale 4: Removing a central line is not within the realm of what family members need to do at home.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-7 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 17 Type: MCSA Prior to discharging the child from the hospital, what routine discharge instructions should the nurse discuss with the family?

1. Monitoring signs and symptoms specific to condition 2. Instruction on performing a medical exam on the child 3. No instructions are needed; the family is familiar with the child.

4. A list of all diagnostic tests obtained during the hospitalization and their results 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.

Rationale 2: The family does not need to know how to complete a medical exam on the child.

Rationale 3: The family knows the child but needs teaching regarding the signs and symptoms to watch for in case of recurrence or complications arise.

Rationale 4: This information was shared with the family as the tests were performed and results received.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-7 Question 18 Type: MCSA A two-year-old child recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant.

The mother best demonstrates understanding of how to give the medication when she: 1. Draws up the medication correctly in an oral syringe and administers it to the child.

2. Acknowledges understanding of written instructions.

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3. Verbalizes how to give the medication.

4. Observes the nurse drawing up the medication and administering it to the child.

Correct Answer: 1 Rationale 1: The best way for the mother to demonstrate understanding is to actually draw up and give the medication.

Rationale 2: Verbalization of how to give the medication and acknowledging understanding of written instructions are methods that might be used to reinforce understanding, but they do not actually demonstrate understanding.

Rationale 3: Verbalizing how to give the medication and acknowledging understanding of written instructions are methods that might be used to reinforce understanding, but they do not actually demonstrate understanding.

Rationale 4: Observing the nurse drawing up and administering the medication may be used in the teaching process.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15-8 Question 19 Type: MCSA 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 the family instruction booklets written in their first language.

2. Give verbal instruction in English and written instructions in the family's first language.

3. Obtain an interpreter to assist the nurse in presenting the instructions and verifying the families’ understanding of the instructions.

4. Provide the instructions in English and ask the family to repeat the instructions to you.

Correct Answer: 3 Rationale 1: 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.

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Rationale 2: The instructions should be both given verbally and written in the family's native language.

Rationale 3: 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.

Rationale 4: Because English is the family's second language, this is inappropriate.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-8 Question 20 Type: MCSA The nurse is teaching family members of a child getting ready for discharge how to administer medication to the child via a G-tube. The nurse created a nursing care plan with the diagnosis: knowledge deficit medication administration per G-tube. The most appropriate outcome for this goal would be that prior to discharge, the family: 1. Understands how to administer the medication.

2. Is able to give a return demonstration.

3. Repeats the instructions.

4. Administers the medication through the G-tube.

Correct Answer: 4 Rationale 1: Understanding is not observable or measurable. It is not the best outcome.

Rationale 2: This outcome is not measureable or observable. The nurse cannot evaluate “Is able to.”

Rationale 3: This outcome is appropriate, but the best option is observing the family administering the medications.

Rationale 4: A return demonstration is the best method to show the parents are capable of performing the task.

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Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-8 Question 21 Type: MCMA Hospitalization is a stressor for all children. Parents often have other responsibilities that prevent them from staying with their child during hospitalization. Which age groups can best tolerate separation from parents during hospitalization?

Standard Text: Select all that apply.

1. Infants birth to five months 2. Infants five months to one year 3. Toddlers and preschoolers 4. School-age children 5. Adolescents Correct Answer: 1,4,5 Rationale 1: Infants in this age group do not recognize parents as separate from themselves so will not feel abandoned when parents do not stay.

Rationale 2: Infants in this age group recognize object permanence and will be aware of the absence of their parents.

Rationale 3: Both groups suffer from separation anxiety and fear of abandonment.

Rationale 4: School-age children are accustomed to dealing with adults other than parents and can better tolerate separation.

Rationale 5: Adolescents are able to understand separation and time and thus will not suffer from separation from parents.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 22 Type: MCMA A preschooler is hospitalized following an injury. The mother has been staying with the child but now must leave to care for the other children. The mother asks the nurse what is the best way to leave. The nurse’s response will include: Standard Text: Select all that apply.

1. Leave the child after he falls asleep so he won’t know you are going.

2. Tell the child you are leaving and identify when you will return by the child’s schedule (e.g., after you eat supper).

3. Have the mother leave an article of clothing behind.

4. Tell the nurse when she is leaving so the nurse can stay with the child while the parents are absent.

5. Plan to leave when the child is having procedures performed as the child will be busy and less aware of the parents’ absence.

Correct Answer: 2,3 Rationale 1: The child will awaken and feel Mom has disappeared. When Mom returns, the child may be unwilling to fall asleep again for fear she will disappear again.

Rationale 2: The child cannot tell time so it is appropriate to associate time of return with an event that the child recognizes rather than give a specific time. It is appropriate for the mother to tell the child she is leaving and promise to return.

Rationale 3: The child recognizes that mother will return for her clothing and this may provide comfort.

Rationale 4: The nurses need to know that the child is alone, but staffing demands will not allow a nurse to sit with the child during the parent’s absence.

Rationale 5: Whenever possible, the parents should be present when procedures are being performed.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5

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Question 23 Type: MCSA A six-year-old child is hospitalized for a surgical procedure. The parents ask if the child’s four siblings can visit.

The best response by the nurse would be: 1. “Let’s plan their visit for a time when the child has received pain medication.”

2. “Only those siblings over 16 will be allowed to visit.”

3. “I don’t think the other children should visit because it might scare them to see their sibling so sick.”

4. “Very young children shouldn’t visit as they may carry germs.”

Correct Answer: 1 Rationale 1: Planning a time to visit when the child is most comfortable will be best for the patient and the siblings.

Rationale 2: Unless hospital policy prevents visitation by younger children, they should be allowed to visit.

Rationale 3: Children should be prepared for a visit, but visits should be allowed. Children who cannot visit often imagine the situation is worse than it is.

Rationale 4: All children may carry germs. Children should be assessed for signs of infection, but if they are free of symptoms, they should be allowed to visit.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-4 Question 24 Type: MCMA The four-year-old child is undergoing cardiac surgery. To reduce the child’s stress in the pre-operative period, the nurses will: Standard Text: Select all that apply.

1. Explain the procedure to the child in simple terms of what the child will see, hear, and feel while awake.

2. Explain to the child that the surgery will fix her “broken” heart.

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3. Allow the parents to accompany the child to the surgical holding room and wait with the child.

4. Allow the child to hold onto their special “teddy bear” while awake.

5. Wait until the child is in the holding room to insert the Foley catheter.

Correct Answer: 1,3,4 Rationale 1: The child does not need to understand the surgical activity while asleep.

Rationale 2: Care must be utilized in selecting terminology for the child. To the child, the heart is not just a muscle, but the center of the child’s love. A “broken” heart may be discarded.

Rationale 3: This is appropriate as parents are the child’s main source of support.

Rationale 4: Children of this age often have security objects; the child should be allowed to hold the object for comfort. Care must be taken that the teddy bear be labeled and returned to the child after the surgical procedure.

Rationale 5: The child is awake in the holding room. It is better to wait until the child is under anesthesia to insert the catheter.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5 Question 25 Type: MCMA An adolescent tells the nurse that the new diagnosis of diabetes has him “stressed out.” The nurse will encourage stress reduction activities, including: Standard Text: Select all that apply.

1. Daily exercise, such as walking.

2. Learning more about his illness.

3. Practicing deep breathing and other relaxation techniques.

4. Not thinking about his diagnosis.

5. Allowing the parents control of his disease.

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Correct Answer: 1,2,3 Rationale 1: Exercise is an effective stress reducer.

Rationale 2: Fully understanding his condition will reduce his stress.

Rationale 3: Relaxation techniques can help reduce stress.

Rationale 4: Keeping feelings and emotions in will increase stress in the adolescent.

Rationale 5: Adolescents like to be in control of themselves and are working on separation from the parents, so it would be inappropriate to encourage the child to give control to others.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5 Question 26 Type: MCMA The physician has ordered the toddler to receive an oral medication. The toddler has fought medication administration in the past. Strategies the nurse will use to administer the medication would include: Standard Text: Select all that apply.

1. Request the medication in liquid form and draw the medication in an oral syringe.

2. Put the medication in a favorite drink in the child’s sippy cup.

3. Allow the mother to administer the medication to the child.

4. Notify the physician to change the route to intravenous.

5. Hold the child down and squirt the medication in the corner of his mouth.

Correct Answer: 1,3 Rationale 1: These activities will make the administration easier.

Rationale 2: This would not be appropriate as it increases the volume that must be administered and may unfavorably change the taste of the drink.

Rationale 3: The child is more willing to take the medication from the mother.

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Rationale 4: This would not be appropriate.

Rationale 5: This could cause the child to choke on the medication and is inappropriate.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5 Question 27 Type: MCSA The pediatric unit manager is making changes to the unit to reduce the stress of the hospitalized children. Which changes have been shown to reduce stress for the children?

1. Having only female nurses on the unit 2. Assigning nurses one-on-one with patients 3. Allowing the nurses to wear colored scrubs in place of white uniforms 4. Having the nurses avoid entering the patient room unless a procedure is to be performed Correct Answer: 3 Rationale 1: The sex of the nurse has not been shown to be a source of stress.

Rationale 2: Staffing patterns will not allow patient one-to-one nurse to patient ratio on the regular pediatric unit.

Rationale 3: This change has been shown to reduce stress in children.

Rationale 4: Nurses should visit when not performing procedures to allow the children to become familiar and comfortable with the nurses.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-5

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Ball, Child Health Nursing, 3/E Chapter 16 Question 1 Type: MCSA The nurse in the long-term care clinic is reviewing the charts of a group of children being seen for follow-up visits in the pediatric clinic. The nurse recognizes that chronic limitations might result from which diagnosis?

1. Pneumonia from Haemophilus influenzae virus 2. Respiratory syncytial virus 3. Streptococcus pneumoniae, a gram-positive diplococcus 4. Congenital heart defect Correct Answer: 4 Rationale 1: Pneumonia is not a chronic limitation.

Rationale 2: Respiratory syncytial virus is a serious infection caused by a virus that affects infants. It does not result in permanent disability.

Rationale 3: Streptococcus pneumoniae, a gram-positive diplococcus, is treatable and will not cause chronic limitation.

Rationale 4: A congenital heart defect can leave a child with a permanent chronic condition.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-1 Question 2 Type: MCSA All of the following children are inpatients on the pediatric unit. Which child is likely to be left with a developmental disability?

1. An 18-month-old admitted with a diagnosis of near drowning

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2. A school-age child newly diagnosed with type 1 diabetes mellitus 3. A toddler with sepsis 4. A two-year-old child with a fractured femur Correct Answer: 1 Rationale 1: Near drowning indicates a period of time when the child was underwater and not breathing; near drowning can leave a child with a permanent chronic condition.

Rationale 2: Diabetes is a chronic disease but does not lead to developmental disabilities.

Rationale 3: Sepsis is treatable and will not result in a developmental disability.

Rationale 4: A fractured femur is limiting to a child but will not leave the child with a chronic, limiting condition.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-1 Question 3 Type: MCSA The school nurse completes an assessment of a six-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. Medically fragile.

2. Developmentally delayed.

3. Mentally retarded.

4. Socially withdrawn.

Correct Answer: 1 Rationale 1: 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.

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Rationale 2: There is no behavioral evidence to support a finding that the child is developmentally delayed.

Rationale 3: There is no evidence in the stem that suggests that this child is mentally retarded.

Rationale 4: The child who is socially withdrawn does not need any special equipment in the classroom.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-2 Question 4 Type: MCMA The nurse is partnering with the family of a hospitalized premature infant who suffered an intraventricular brain hemorrhage. After three months in the neonatal intensive care unit (NICU), the infant is being discharged. Which activities will the nurse suggest to the family to help stimulate the infant’s development?

Standard Text: Select all that apply.

1. Using a day care for stimulation 2. Discouraging sibling interaction 3. Holding and rocking the infant 4. Interacting face to face 5. Talking softly and singing to the infant Correct Answer: 3,4,5 Rationale 1: 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.

Rationale 2: Sibling interaction is important and should be encouraged.

Rationale 3: Holding and rocking the infant stimulates the infant's sense of motion, facilitating parent-infant bonding.

Rationale 4: Interacting face to face stimulates the infant's sense of vision, facilitating parent-infant bonding.

Rationale 5: Talking softly and singing to the infant are activities that stimulate the infant's senses of hearing, touch, and motion, facilitating parent-infant bonding.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-3 Question 5 Type: MCSA 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. Preschoolers 2. School-age children 3. Adolescents 4. Toddlers Correct Answer: 2 Rationale 1: Preschoolers do not have the cognitive and psychomotor skills for these tasks.

Rationale 2: School-age children are developing a sense of industry and can begin assuming responsibility for self-care.

Rationale 3: Adolescents should already be well accomplished at self-care.

Rationale 4: Toddlers do not have the cognitive and psychomotor skills for these tasks.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-3 Question 6 Type: MCSA

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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. More concern for their parents.

2. A decreased concern about their appearance.

3. An altered body image.

4. Higher self-esteem.

Correct Answer: 3 Rationale 1: As adolescents develop a sense of identity, they are focused on themselves and the present.

Rationale 2: Adolescents with chronic conditions will have a heightened concern about their appearance.

Rationale 3: Adolescents with chronic conditions might have inaccurate assessments of their body image.

Rationale 4: Adolescents with chronic conditions have low self-esteem when comparing their bodies with those of their peers.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-3 Question 7 Type: MCSA The nurse is working with the parents of a child with a chronic condition. The nurse concludes that the parents’ caregiver burden might become overwhelming when the mother states which of the following?

1. "My mother moved in and helps us with the care of our family."

2. "I chose to quit my job to be home with my child, and my husband helps in the evening when he can."

3. "I have to care for my child day and night, which leaves little time for me."

4. "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."

Correct Answer: 3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: The family's pitching in to help indicates family support.

Rationale 2: The mother chose to care for the child and receives help from the husband.

Rationale 3: No respite time from caregiving responsibilities could lead to overwhelming caregiver burden.

Rationale 4: Substituting generic for brand-name medications will not result in caregiver burden.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-4 Question 8 Type: MCMA 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 activities?

Standard Text: Select all that apply.

1. Fostering social relationships 2. Exercising 3. Developing a hobby 4. Moving away 5. Sleeping more than 9 hours per 24-hour period Correct Answer: 1,2,3 Rationale 1: Fostering social relationships contributes to social and mental rest and restoration.

Rationale 2: Exercising contributes to physical restoration.

Rationale 3: Developing a hobby contributes to physical, spiritual, social, and mental rest and restoration.

Rationale 4: Moving away is an avoidance behavior that does not address exhaustion from overwhelming caregiving responsibilities.

Rationale 5: Sleeping more than the body requires is an avoidance behavior.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-5 Question 9 Type: MCSA 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. Pathologic grieving.

2. Compassion fatigue.

3. Chronic sorrow.

4. Dysfunctional parenting.

Correct Answer: 3 Rationale 1: Pathologic grieving results when persons do not move through the stages of grief to resolution.

Rationale 2: Compassion fatigue is experienced by caregivers as their ability to feel compassion is exhausted.

Rationale 3: 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.

Rationale 4: Dysfunctional parenting involves inadequately meeting the needs of children.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-4 Question 10 Type: MCSA

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The nurse is conducting a nursing assessment of the parent and child with severe cerebral palsy during a routine clinic visit. Which of the following is important for the nurse to include on this assessment?

1. Measuring the urine output 2. Measuring the child's head circumference 3. Observing the parent-child relationship 4. Observing how the child interacts during play Correct Answer: 3 Rationale 1: Measuring urine output is not important unless there are problems with the bladder.

Rationale 2: Measuring the child's head circumference is not an important assessment at this time.

Rationale 3: Observing the parent-child relationship is important to the success of health supervision for both the child and parents.

Rationale 4: Playtime is not important during this time.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-4 Question 11 Type: MCSA The nurse is conducting an educational program for parents of children with chronic conditions. Which statement by a parent requires additional nursing interventions?

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 may need specialized education."

4. "I know my child will have to stay on a special diet."

Correct Answer: 1 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Chronic conditions might require lifetime dependence on medication.

Rationale 2: Children with chronic conditions typically need assistance with daily living activities.

Rationale 3: A child with a chronic condition may require specialized education.

Rationale 4: Depending on the diagnosis, children with chronic conditions might require a special diet.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16-4 Question 12 Type: MCSA An adolescent has recently been diagnosed with type 1 diabetes mellitus and is on dietary restrictions and daily insulin. The nurse is teaching the adolescent’s family members about the disease and treatment. The nurse will warn the family that the adolescent, upon returning to school, may: 1. Recognize that there is no difference between her and her classmates.

2. Not experience social stigma.

3. Acknowledge her condition to her classmates.

4. Not adhere to dietary recommendations.

Correct Answer: 4 Rationale 1: Adolescents might recognize differences between themselves and others, such as appearance, abilities, and social skills, for the first time.

Rationale 2: Adolescents might experience social stigma when their classmates find out about a health condition.

Rationale 3: Adolescents will attempt to hide their health conditions from their classmates.

Rationale 4: Adolescents have poorer eating habits than all other age groups, and adolescents with diabetes may not adhere to necessary dietary restrictions.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-6 Question 13 Type: MCMA The nurse is working with a 20-year-old who is medically fragile. It is the policy of the clinic to only see patients from birth to 21 years of age. The nurse is responsible for assisting the individual and family to transition to adult health care. The nurse recognizes that the individual may face difficulties related to: Standard Text: Select all that apply.

1. No longer qualifying for the state’s child health insurance program and becoming uninsured.

2. Wanting to start fresh with the new healthcare provider and refusing to allow transfer of their records to the new agency.

3. Adult clinics being unwilling to accept this chronically ill individual into their practice.

4. The parents choosing an adult clinic that is not the one the individual would like to attend.

5. Being unwilling to transition to the adult clinic due to the relationships they have with the pediatric clinic.

Correct Answer: 1,3,5 Rationale 1: Most states end their state insurance at the age of 21. Adults who are medically fragile are often unable to find an insurance carrier that will cover their health care needs.

Rationale 2: The individual and family will recognize that in order to get continuity of care, the new clinic will need information about past and current treatment.

Rationale 3: Many clinics are not accepting new patients or may accept new patients but are unwilling to accept a patient who is medically fragile.

Rationale 4: The parents and individual will usually decide together which adult clinic to attend.

Rationale 5: Patients and family members who have been attending a clinic for so many years are often reluctant to transition to another clinic.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-6 Question 14 Type: MCSA 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. Isolation.

3. Normalization.

4. Interaction.

Correct Answer: 3 Rationale 1: The family is not staying at home because one member cannot walk.

Rationale 2: The family is moving on to full participation in life.

Rationale 3: The family is normalizing their life with their children by their activities.

Rationale 4: The family is interacting with others through the process of normalization.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16-5 Question 15 Type: MCMA After the infant is diagnosed as a child with a chronic health condition, the family is assigned a nurse working as a case manager. The nurse would explain that as a case manager, the nurse’s role will include: Standard Text: Select all that apply.

1. Limiting the number of visits to the health care facility.

2. Preventing duplication of services.

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3. Improving the quality of life for the child and parents.

4. Recognizing the equipment needs of the child and providing assistance with equipment acquisition.

5. Visiting the child in the home to assist with physical care.

Correct Answer: 2,3,4 Rationale 1: Although well managed care may reduce illnesses and thus visits to the health care facility, limiting visits is not a function of the case manager.

Rationale 2: Because many children who are chronically ill are seen by many doctors and clinics, there is often a duplication of services. Case managing coordinates between the various clinics and doctors to prevent duplication.

Rationale 3: Case managing has many modes of improving the quality of life for children and parents. By coordinating care, the child can often be seen by several physicians during the same visit, thus improving the quality of life.

Rationale 4: The case manager will assist the family in meeting the needs of the child, including helping with identifying and acquiring equipment necessary for caring for the child.

Rationale 5: The case manager does not provide direct patient care.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-7 Question 16 Type: MCSA The nurse works in a clinic for medically fragile children who require constant home care. The nurse has noticed that a high percentage of the families wind up divorcing. In an attempt to reduce the divorce rate among the parents, the nurse creates an educational session for parents of medically fragile children that focuses on the need for: 1. Communication.

2. Financial stability.

3. Meeting the child’s physical needs.

4. The state laws that have relevance to the medically fragile child.

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Correct Answer: 1 Rationale 1: Both partners need to be able to communicate honestly and frequently to maintain the marriage relationship.

Rationale 2: Finances will be a problem for the family as the cost of care of medically fragile child can be high.

Nurses may refer to community resources but cannot solve all financial problems.

Rationale 3: The nurse will teach parents how to meet the child’s physical needs on a one-to-one basis, not in a group session.

Rationale 4: This will not reduce the divorce rate.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-4 Question 17 Type: MCMA The school nurse is reviewing the records of all incoming kindergarten students. The nurse recognizes that an individualized education plan (IEP) will be required for which children?

Standard Text: Select all that apply.

1. The child with diabetes controlled with insulin 2. The child with a casted arm due to a fracture 3. The child with a hearing deficit 4. The child with autism 5. The child with an IQ of 60 Correct Answer: 3,4,5 Rationale 1: This child may need an individual health plan but does not require an IEP. Rationale 2: This is not a chronic problem and does not require an IEP. Rationale 3: This child will need modification of the educational plan in order to be successful.

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Rationale 4: The child diagnosed on the autism spectrum will have special educational needs that will be determined by the IEP. Rationale 5: The child with an IQ of 60 is intellectually disabled and will require an individual education plan.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16-6 Question 18 Type: MCSA The nurse recommends to the family of a child with severe cerebral palsy that they enroll their child in hippotherapy. The nurse would explain that hippotherapy includes: 1. Water exercises to increase muscular strength.

2. Use of braces and walkers to support walking.

3. Dietary therapy to maintain a normal weight.

4. Horseback riding, or hippotherapy, improves posture and balance and allows the child to participate in a physical activity.

Correct Answer: Rationale 1: Hippotherapy does not involve water exercises.

Rationale 2: Hippotherapy does not involve bracing and the use of walkers.

Rationale 3: Hippotherapy is not related to nutrition.

Rationale 4: True Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 19 Type: MCSA The mother of a 16-year-old child with multiple medical and developmental issues says to the nurse: “There are times that I think about just walking out of the house and not coming back.” Which would be an appropriate nursing diagnosis for this mother?

1. Caregiver role strain related to providing 24-hour care for a child with medical and developmental issues 2. Risk for injury (maternal) related to overwhelming demands of the medically fragile child 3. Knowledge deficit (maternal) nursing care of the child 4. Health seeking behaviors (maternal) related to interest in learning to care for her child Correct Answer: 1 Rationale 1: This diagnosis describes the effect of this child’s care on the mother.

Rationale 2: There is no indication of a risk for injury in the stem.

Rationale 3: This question does not indicate a lack of knowledge by the mother but frustration due to the daily demands of caring for her child.

Rationale 4: There is no indication in the stem that the mother wants to learn more about medical care for her child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 16-6 Question 20 Type: MCSA The three-year-old child with cystic fibrosis has just been discharged from the hospital following a two-week stay due to a respiratory infection. The child has a post-discharge office visit the next day. During the office visit, the mother mentions that the child was toilet trained before hospitalization but now is having accidents. Which response by the nurse would be most appropriate?

1. “This is probably a reaction to the antibiotics and will disappear when the antibiotics are finished.”

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2. “Urinary incontinence is a common symptom of progression of cystic fibrosis. Be sure to notify the physician of this change.”

3. “The child may have a urinary tract infection and needs to be evaluated.”

4. “Children often regress after hospitalization. Be patient and remind him to go to the bathroom frequently.”

Correct Answer: 4 Rationale 1: Antibiotic therapy does not cause incontinence.

Rationale 2: Urinary incontinence is not a symptom of cystic fibrosis.

Rationale 3: There are no symptoms of a UTI. Rationale 4: Regression is a common response to hospitalization.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-3 Question 21 Type: MCSA Shortly after birth, all newborns are tested for phenylketonuria. The test results are not available before mother and baby are discharged from the hospital. When the diagnosis of PKU is made, the most appropriate means of informing the parents would be: 1. Immediately in a phone call requesting a follow-up office visit 2. In a certified letter explaining the diagnosis and requesting the parents make a pediatric office appointment.

3. In a group meeting of all parents whose children tested positive for phenylketonuria during the last two months.

4. In person with the physician and both parents present.

Correct Answer: 4 Rationale 1: Providing the parents information of a chronic health problem of their newborn should not be done over the phone.

Rationale 2: This information should be provided to the parents in person.

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Rationale 3: This information should be shared on a one-to-one basis.

Rationale 4: The appropriate environment allows for privacy and freedom from interruptions. The parents should be allowed other support people to be present as they request.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16-4 Question 22 Type: MCMA Following an automobile accident in which the child received a traumatic head injury, the child has been hospitalized for two weeks. The parents have just been informed that their four-month-old child will have longterm consequences due to the injury, including intellectual disability and cerebral palsy. The parents express anger at the diagnosis and project that anger on the nursing staff. The response by the nursing staff should include: Standard Text: Select all that apply.

1. Referring the family to the hospital administrator.

2. Recognizing that the parents’ anger is a normal response to the news.

3. Continuing to provide physical and emotional care to the child and family.

4. Offering hospital resources to the parents in addition to continued nursing support.

5. Explaining to the family that you are sorry about their child’s injury but suggest they transfer the child to another hospital for their own comfort.

Correct Answer: 2,3,4 Rationale 1: The hospital administrator will be unable to meet their needs or to calm their anger.

Rationale 2: Parents grieve for the loss of the perfect child. This is a normal reaction.

Rationale 3: The nursing staff will continue to provide physical and emotional care to the child and family.

Rationale 4: It is appropriate to offer the hospital chaplain and other mental health workers in addition to continued support from the nursing staff.

Rationale 5: This option is a resolution for the nursing staff but not for the parents.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-5

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Ball, Child Health Nursing, 3/E Chapter 17 Question 1 Type: MCSA The nurse is caring for an eight-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. Sedate the child as needed.

2. Place soft wrist restraints on the child.

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: 2 Rationale 1: Due to the head injury, it is not feasible to sedate the child.

Rationale 2: Children may interfere with treatment by pulling or removing medical devices; soft restraints may be necessary to prevent them from pulling on or removing medical devices.

Rationale 3: It is not feasible for the parents to watch the child at all times.

Rationale 4: The child may not understand what the nurse is trying to convey.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-5 Question 2 Type: MCMA 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 school-age children with life-threatening illness are: Standard Text: Select all that apply.

1. Painful and invasive procedures.

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2. Fear of the medical team.

3. Disfigurement.

4. Separation from family.

5. Loss of self-control.

Correct Answer: 1,3,4,5 Rationale 1: Fear of painful and invasive procedures will cause stress for children.

Rationale 2: School-age children do not usually have a fear of the medical team.

Rationale 3: One stressor for children is fear of disfigurement.

Rationale 4: Although school-age children can separate from their parents, children will find the separation a stressor when the acuity of their illness increases.

Rationale 5: Children who are hospitalized fear losing control of self.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-2 Question 3 Type: MCSA The nurse is preparing a seriously ill child for a procedure. Which age group of children benefits most from being talked to, soothed, and touched during and after the procedure?

1. Preschoolers 2. School-age children 3. Adolescents 4. Toddlers Correct Answer: 4 Rationale 1: Provide preschool children with an explanation of the sensations they can expect to experience.

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Rationale 2: School-age children and adolescents want an explanation of the sensations they can expect.

Rationale 3: Provide adolescents with an explanation of the sensations they can expect to experience (temperature, vibrations, sounds, smells, tastes, sight).

Rationale 4: Toddlers will benefit from being talked to, soothed, and touched during and after the procedure.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-5 Question 4 Type: MCSA An adolescent with cystic fibrosis is intubated with an endotracheal tube. Which is the most appropriate nursing diagnosis for the adolescent?

1. Impaired social interaction related to hospitalization and separation from peers 2. Delayed growth and development related to prolonged hospitalization and life-threatening condition 3. Powerlessness (moderate) related to inability to speak to or communicate 4. Potential for imbalanced nutrition, more than body requirements related to inactivity Correct Answer: 3 Rationale 1: Although the adolescent will have difficulty with social interaction, that is not the primary concern at this time.

Rationale 2: There may be issues related to growth and development, but they are not the primary concerns at this time.

Rationale 3: The adolescent values communication and might feel frustrated that he cannot speak and make his wishes known while intubated.

Rationale 4: The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Global Rationale: Cognitive Level: Analyzing Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17-5 Question 5 Type: MCSA A 16-year-old boy has a stiff neck, a headache, a fever of 103° Fahrenheit, and purpuric lesions 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. Fear of getting behind in schoolwork 2. Fear of painful procedures and bodily mutilation 3. Separation from friends and permanent changes in appearance 4. Separation from parents and home Correct Answer: 3 Rationale 1: School-age children are developing a sense of industry and fear getting behind in schoolwork.

Rationale 2: Preschoolers fear pain and bodily mutilation.

Rationale 3: 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.

Rationale 4: Separation from parents and home is the main psychological stressor for infants and toddlers.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-2 Question 6 Type: MCSA A six-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 he collided with a car. The parents appear lost and unable to take in the medical discussion. Which nursing diagnosis is most appropriate for the parents of this child?

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1. Parental role conflict related to child's wellness vs. illness 2. Guilt related to buying a bicycle for the child 3. Family coping: compromised, related to the critical injury of the child 4. Knowledge deficit home care of fractured femur Correct Answer: 3 Rationale 1: At this point, the parents will not be conflicted or confused whether they want their child well or ill.

Rationale 2: The parents may experience guilt for purchasing a bicycle and not providing a helmet for the child, but the parents’ behavior does not suggest this diagnosis at this time.

Rationale 3: The parents are displaying ineffective coping behaviors. The parents might be experiencing hopelessness, frustration, and anxiety, and they are not coping well as a family unit.

Rationale 4: During the initial phase of the accident, the family is not focusing on discharge planning and care of the fractured femur.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17-4 Question 7 Type: MCMA In caring for a child with a life-threatening illness, the nurse should anticipate the parent's reaction to the child illness. Which response should the nurse anticipate the parent will experience?

Standard Text: Select all that apply.

1. Anticipatory waiting 2. Post-traumatic stress disorder 3. Deprivation and loss 4. Anger and guilt 5. Readjustment and mourning Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1,3,4,5 Rationale 1: Once the child's condition is stabilized and survival seems likely, parents often move into a period of anticipatory waiting.

Rationale 2: Children may develop posttraumatic stress disorder following a life-threatening injury. It is not a reaction of the parents.

Rationale 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.

Rationale 4: Anger and guilt surface as parents become more aware of their child's illness or injury.

Rationale 5: The last stage that parents experience is readjustment or mourning.Readjustment is experienced as the child recovers.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-4 Question 8 Type: MCMA A child is admitted to the PICU following an accident. The parents ask the nurse about bringing the siblings to visit. The nurse will meet with the siblings and the parents and: Standard Text: Select all that apply.

1. Describe the sights, sounds, and smells of the pediatric intensive care unit.

2. Provide a simple explanation of the other children being cared for in the PICU. 3. Explain the child’s injuries in ways that are appropriate to the ages of the siblings.

4. Describe how the child looks.

5. Explain why the siblings will not be able to visit until the child has stabilized and is progressing.

Correct Answer: 1,3,4 Rationale 1: Describe the hospital environment, including equipment, sounds, and smells.

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Rationale 2: The siblings should not hear about other patients and the other patients should be screened from view of any visitors.

Rationale 3: Using a doll, drawing pictures, or showing an actual picture of the child can help prepare the siblings.

Rationale 4: Before the visit, talk with the siblings about what to expect, and describe how their sibling will look.

Rationale 5: Siblings should be allowed to visit. Such a visit should be encouraged whether the child is improving or deteriorating.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-4 Question 9 Type: MCSA 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. "Why can't you visit after work every day?"

2. "One of you could take a leave of absence to be here more."

3. "Perhaps the grandparents can make the visits for you."

4. "Parents often feel this way; you can call any time to see how your baby is doing."

Correct Answer: 4 Rationale 1: This statement does not focus on how the parents feel and may increase their feelings of guilt.

Rationale 2: 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. It may add to feelings of inadequacy.

Rationale 3: While grandparents visiting may increase their comfort about their baby, it will not reduce the parents’ feelings of guilt.

Rationale 4: This statement is therapeutic; it focuses on feelings and offers support to the parents.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-5 Question 10 Type: MCMA In which settings is the nurse most likely to work with parents experiencing shock and disbelief related to the sudden onset of a life-threatening illness for their child?

Standard Text: Select all that apply.

1. Emergency departments 2. Pediatric Intensive Care Unit 3. Operating room 4. Neonatal Intensive Care Unit 5. Pediatric cancer clinics Correct Answer: 1,2,4 Rationale 1: Sudden onset of life-threatening conditions of children may occur in the emergency department.

Rationale 2: Children admitted to the PICU often face the sudden onset of life-threatening illnesses.

Rationale 3: Although the operating room can have sudden onset of life-threatening conditions, the parents are not in the operating room.

Rationale 4: The condition of infants in the NICU can deteriorate suddenly, and the parents may respond with shock and disbelief.

Rationale 5: Many children attending the pediatric cancer clinics have life-threatening illnesses, but the onset is not sudden and the parents at the clinic will not typically be expressing shock and disbelief.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-1

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Question 11 Type: MCSA A new pediatric hospital is under development. A suggestion that has been shown to improve the psychological comfort of children in the Pediatric Intensive Care Unit would be: 1. Limiting the number of visitors to allow the child to rest.

2. Allowing the parents to visit every two hours for 10 to 15 minutes.

3. Planning all rooms to be two-patient rooms so each child will have another child for comfort and support.

4. Providing a bed for a parent to stay with the child in the PICU. Correct Answer: 4 Rationale 1: Family members provide emotional support for the child. Limiting visitors will not provide comfort.

Rationale 2: Limiting parents’ visits will not provide emotional support to the children.

Rationale 3: Sick children look to their parents for support and comfort, not to other children.

Rationale 4: Studies have shown that allowing the parents to stay full time with the children has been shown to increase comfort and support for the child and the parent.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-5 Question 12 Type: MCSA A premature infant is admitted to the Neonatal Intensive Care Unit. The infant is in critical condition, and the outcome is questionable. Nursing behaviors that will promote visitation include: 1. Explaining to the parents that everything possible is being done for their infant.

2. Smiling at the parents and making them welcome when they come to visit.

3. Allowing alone time with their infant when they visit.

4. Introducing the parents to the other parents visiting their babies.

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Correct Answer: 2 Rationale 1: This reassurance will not increase parental visits.

Rationale 2: When parents feel they are not “strangers” in the unit, they will be more likely to visit.

Rationale 3: Avoidance of the parents will not make the parents want to visit more often.

Rationale 4: It is appropriate to encourage parents to meet other parents, but this will not increase the parents’ willingness to visit.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-5 Question 13 Type: MCSA Twenty-four hours after being transferred from the pediatric intensive care unit to the regular pediatrics floor, the seven-year-old child is asked about his experience in the PICU. The child says he was not in the PICU but came directly to the floor from the ambulance ride. The nurse recognizes this is a coping behavior for the child known as: 1. Repression.

2. Regression.

3. Amnesia.

4. Developmental delay.

Correct Answer: 1 Rationale 1: Repression is the involuntary forgetting of an experience due to the stress of the situation.

Rationale 2: Regression is a return to earlier behaviors, such as loss of continence or asking for a bottle in a toddler.

Rationale 3: Amnesia is the loss of memory that can result from a head injury. There is no indication of a head injury occurring in this child.

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Rationale 4: Developmental delay refers to a child whose behavior is not appropriate for the chronologic age of the child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-2 Question 14 Type: MCSA Following a tornado destroying the family home and injuring all family members, the four-year-old child is admitted to the Pediatric Intensive Care Unit. All other family members are hospitalized at a different hospital.

The nursing staff can provide the four-year-old with a sense of security by: 1. Providing new toys for the child.

2. Asking a hospital volunteer to visit the child daily and stay as long as possible.

3. Explaining to the child that mom and dad also are sick and cannot come to visit.

4. Keeping the child’s security blanket with the child at all times.

Correct Answer: 4 Rationale 1: Toys are beneficial to normalizing the situation but will not provide as much comfort as the parents’ presence.

Rationale 2: Stability of the people around the child will add to the comfort but is not the best response.

Rationale 3: The child is too young to grasp the situation.

Rationale 4: A security blanket or teddy bear from home will provide the most comfort to the child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-3 Question 15 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA A baby is born at 32 weeks’ gestation and is admitted to the NICU. After 4 difficult weeks, the child’s condition has improved and survival seems guaranteed. The mother comes every day to feed the infant. Between feedings, the mother sits alone in the waiting room. The mother tells the nurse that she feels her life is in a holding pattern, not yet being a parent but no longer anticipating the excitement of the planned delivery. The nurse recognizes that the mother’s reaction could be defined as: 1. Shock and disbelief.

2. Anticipatory waiting.

3. Readjustment.

4. Mourning.

Correct Answer: 2 Rationale 1: This behavior does not describe shock and disbelief.

Rationale 2: The mother is describing the reaction period often described as anticipatory waiting. She cannot get on with her life until the child’s condition improves and the child is discharged from the NICU. Rationale 3: Readjustment occurs when the child’s condition has improved to the point of transfer or discharge.

When this occurs, the mother will not be “waiting,” but she will be looking forward to starting life with the new baby.

Rationale 4: When the child’s condition deteriorates, the mother would display symptoms of grief.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-3 Question 16 Type: MCSA A young child is admitted to the hospital following a serious injury while on a field trip with his school class.

When the parents arrive at the emergency room, the nurse recognizes that the parents have only limited English.

The nurse will: 1. Speak slowly and clearly so the parents can understand.

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2. Have a translator/interpreter present when the nurse and physician describe the child’s condition to the parents.

3. Have a family member who speaks English translate for the family 4. Give the parents a pamphlet written in their primary language that describes the hospital routine.

Correct Answer: 2 Rationale 1: The parents will not understand, not because they can’t hear, but because they speak little English.

Speaking more clearly will not be very helpful.

Rationale 2: Even if the parents have some English, the stress of the situation may impair communication without a translator.

Rationale 3: The nurse cannot be sure that the family member is translating accurately. In addition, this could violate HIPAA regulations by sharing information with someone other than the parents without the parents’ full agreement. They cannot agree if they do not understand.

Rationale 4: The pamphlet will not explain what is wrong with their child and therefore is not the best solution.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-5 Question 17 Type: MCMA Complementary activities that may reduce stress for the child and parents in the Pediatric Intensive Care Unit include: Standard Text: Select all that apply.

1. Prayer.

2. Maintaining silence in the PICU. 3. Maintaining a sterile-appearing hospital room.

4. Music playing softly.

5. Encouraging the parents to read age-appropriate books to the child.

Correct Answer: 1,4,5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: For the family with religious beliefs, prayer can provide comfort and support.

Rationale 2: Absolute silence may make the child feel abandoned and is not a comfort.

Rationale 3: The physical appearance of the PICU can be threatening. A colorful, home-like appearance will decrease stress.

Rationale 4: Music has been shown to reduce stress and slow heart and respiratory rates.

Rationale 5: The child will be comforted by hearing the parent’s voice. The parents will be comforted because they will feel they are doing something to benefit their child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-5 Question 18 Type: MCMA The hospital recently changed its policy and now allows families members to be present during resuscitation of their child. The benefits expected from this policy change include: Standard Text: Select all that apply.

1. Positive patient outcomes increase due to the patient hearing family voices during the resuscitation.

2. Parents are reassured that everything possible is being done.

3. Professional behavior by the healthcare team improves.

4. Parental feelings of helplessness decrease.

5. Grieving and closure are facilitated.

Correct Answer: 2,3,4,5 Rationale 1: No studies have shown that the patient outcome is improved.

Rationale 2: This statement is accurate.

Rationale 3: When the healthcare team is aware that the family is present, their behavior is more professional and appropriate.

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Rationale 4: Parents feel that they are involved and not just waiting.

Rationale 5: It increases the sense of reality to be present during unsuccessful resuscitation events.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-4 Question 19 Type: MCSA A child has been comatose in the PICU for three days. The parents have been at the child’s bedside or in the waiting room the entire time. Which statement by the nurse would be most helpful in promoting the parents to take a break?

1. “You’ve been here three days. It is time for you to go home and take a shower.”

2. “Your child isn’t aware you are here anyway, so why don’t you take a break?”

3. “I’ll be with your child, so go home and get a good nap.”

4. “I know you are concerned and afraid to leave. If you’d like to take a short walk, you can leave me your cell phone number and I’ll call you if there are any changes.”

Correct Answer: 4 Rationale 1: This statement is a negative statement and does not address the parents’ emotional needs.

Rationale 2: The parents need to feel needed. It is also impossible to know whether or not the child is aware of the parents’ presence.

Rationale 3: Whereas it may be a comfort to know the child will not be alone, the parents may be uncomfortable leaving the child for any length of time.

Rationale 4: This answer promises to maintain contact and encourages the parents to leave. It also recognizes the parents’ concerns.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-4 Question 20 Type: MCSA An adolescent with a gunshot wound presents to the emergency department with his distraught parents. He states that he saw a classmate shoot his teacher and several other students. As a result of the shooting incident, the nurse expects this adolescent to be at risk for which disorder?

1. Conduct disorder 2. Depression 3. Post-traumatic stress disorder 4. School phobia Correct Answer: 3 Rationale 1: Conduct disorder could possibly occur later.

Rationale 2: Depression could possibly occur later.

Rationale 3: Acute stress, parental stress, and the degree of the psychological trauma exposure are variables predictive of post-traumatic stress disorder (PTSD).

Rationale 4: School phobia could possibly occur later.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17-2

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Ball, Child Health Nursing, 3/E Chapter 18 Question 1 Type: MCSA 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 representative of the development of which age group?

1. Adolescents 2. Preschoolers 3. School-age children 4. Infants Correct Answer: 2 Rationale 1: Adolescents have a mature understanding of death, but the normal developmental milestones of adolescence add to their problems in facing a terminal illness.

Rationale 2: Preschool-age children can see their bodies deteriorate and feel the effects of medications used during disease progression and treatment.

Rationale 3: School-age children have subtle fears about body integrity and anxieties about the seriousness of their illness.

Rationale 4: 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 their parents.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-1 Question 2 Type: MCMA The nurse is caring for a child with a terminal illness. Physical care for the dying child would include which interventions?

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Standard Text: Select all that apply.

1. Providing oral care to moisten a dry mouth 2. Administering ordered laxatives to counter the effects of opioids 3. Encouraging a favorite food 4. Keeping the child pain-free 5. Taking vital signs and blood pressure every two hours Correct Answer: 1,2,3,4 Rationale 1: Oral care will provide moisture to a dry mouth and increase the child’s physical comfort.

Rationale 2: Opioids given for pain often cause constipation. Relief of constipation will increase the child’s comfort.

Rationale 3: Offering and encouraging favorite foods and liquids as tolerated should be part of the physical care.

Rationale 4: Providing analgesia to promote optimal pain relief. Oral, transdermal, or rectal analgesia is available for families who choose to withhold intravenous fluids.

Rationale 5: Measuring vital signs will be intrusive, uncomfortable, and provide no benefit to the dying child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-6 Question 3 Type: MCSA The nurse is providing postmortem care to a child. Along with following the facility's guidelines, what else should the nurse consider?

1. Identifying the family's wishes for postmortem care before performing care 2. Avoiding delay in moving the body to the morgue 3. Removing all articles from patient's body 4. Leaving all equipment in the room during postmortem care Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: There are many cultural variations in how the body should be handled after death. For example, in some cultures, the family will wish to wash and dress the body.

Rationale 2: The family may want to spend time with the deceased and should be allowed to spend as much time as they need with the child’s body.

Rationale 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.

Rationale 4: The nurse can remove the equipment in the room during postmortem care.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-7 Question 4 Type: MCSA

The nurse is working in a PICU with several children with life-threatening illnesses. The children come from a variety of cultural and religious groups. Because of their religious beliefs, the parents of which religious group should not be contacted regarding organ and tissue donation?

1. Jehovah's Witness 2. Islam 3. Hinduism 4. Buddhism Correct Answer: 1 Rationale 1: Jehovah's Witnesses forbid organ donation.

Rationale 2: In Islam, organ donation is acceptable.

Rationale 3: In Hinduism, autopsy and organ donation are acceptable.

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Rationale 4: In Buddhism, organ donation is considered an act of mercy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-2 Question 5 Type: MCSA 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 the nurse if he is dying. Which of the following would be the most appropriate action by the nurse at this time?

1. Ignore the child's question and change the subject.

2. Offer to bring in the child life therapist.

3. Suggest the parents meet with the health care team.

4. Tell the child he is dying and offer to stay with him.

Correct Answer: 3 Rationale 1: Changing the subject or ignoring the child is not appropriate.

Rationale 2: This is an avoidance technique. Avoiding the subject is not an option.

Rationale 3: 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.

Rationale 4: This is going against the parents' wishes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-4 Question 6 Type: MCMA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

A three-year-old child has a brain tumor and is now dying. The child has an Allow Natural Death order (AND order). Which of the following care and interventions are allowed for a child with an AND order?

Standard Text: Select all that apply.

1. Oxygen 2. Suctioning 3. Use of a ventilator if respiratory failure occurs 4. Pain control 5. Cardiac compressions Correct Answer: 1,2,4 Rationale 1: The child with an AND order may still receive oxygen to provide comfort.

Rationale 2: Suctioning of secretions would be appropriate for a child with an AND order.

Rationale 3: In most cases when a patient has an AND and respiratory arrest occurs, there will be no attempts to initiate resuscitation activities.

Rationale 4: The goal of AND orders is to maintain comfort of the patient while not continuing futile efforts to restore life. Pain control would be appropriate.

Rationale 5: Should the heart fail, external attempts to restart the heart would be inappropriate.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-4 Question 7 Type: MCSA The nurse is taking care of a child who is showing signs of imminent death. What changes should the nurse expect to see related to the cardiovascular system?

1. An increase in the volume of Korotkoff's sounds 2. Mottling, cool and clammy skin Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Peripheral pulses will remain when the heart beat is not heard on auscultation.

4. Increase in cardiac output Correct Answer: 2 Rationale 1: A change in pulse pressure and a decrease in the volume of Korotkoff's sounds indicate imminent death.

Rationale 2: Peripheral circulation decreases, leading to diaphoresis, clammy and cool skin, and changes in skin coloring such as mottling or cyanosis.

Rationale 3: The heart rate might initially increase as hypoxia develops, then the heart rate and blood pressure decrease, resulting in decreased cardiac output.

Rationale 4: The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-5 Question 8 Type: MCSA The nurse is taking care of a child who is terminally ill. The nurse notices the child is having periods of shallow breathing followed by short periods of apnea. The nurse recognizes that this is: 1. Normal respiratory function of a young child.

2. Cheyne-Stokes respiration, which is a sign of imminent death. The child should be assessed for other signs of imminent death.

3. Dyspnea secondary to muscle relaxation.

4. A sign of air hunger.

Correct Answer: 2 Rationale 1: This is not normal respiratory function in a young child.

Rationale 2: Cheyne-Stokes respiration (periods of shallow breathing alternating with apnea) is a sign of imminent death.

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Rationale 3: Dyspnea refers to difficulty breathing. The muscle relaxation is a symptom of imminent death and is associated with the “death rattle.”

Rationale 4: With air hunger, the child’s facial expression may reflect panic and the child may gasp for air.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-5 Question 9 Type: MCSA The nurse has been working with the parents of a dying child. The nurse has explained signs of imminent death.

Which statement by the parents indicates that they understand the teaching?

1. “I understand that my child can see me until the very end.”

2. “Dying children always lose consciousness a few hours before they pass.”

3. “My child may become flushed as his heart slows down.”

4. “My child may see visions that I cannot see.”

Correct Answer: 4 Rationale 1: Visual acuity may deteriorate as death approaches. This statement is not totally accurate.

Rationale 2: Some children may lose consciousness; others may have drowsiness, confusion, or agitation in the last few hours.

Rationale 3: A slowing of the heart will lead to a pale, not flushed, skin.

Rationale 4: Some children speak of seeing people or objects that others cannot see.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 10 Type: MCMA 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?

Standard Text: Select all that apply.

1. Loneliness 2. Guilt 3. Anger 4. High energy 5. Depression Correct Answer: 1,2,3,5 Rationale 1: The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

Rationale 2: The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

Rationale 3: The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

Rationale 4: High energy is not felt during the mourning period.

Rationale 5: The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-7 Question 11 Type: MCSA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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 being bad, and the sibling is being punished.

2. The child's having a fight with their sibling.

3. The child's having thoughts about their sibling dying.

4. Their parents' not liking that sibling.

Correct Answer: 3 Rationale 1: Preschool-age children do not have a fear of being bad and the sibling's subsequently being punished.

Rationale 2: Fighting is normal, and preschool-age children do not have those thoughts.

Rationale 3: Preschool-age children might fear that they caused their brother or sister to be injured or become ill, or they may worry that bad thoughts on their part brought on the illness.

Rationale 4: Preschool-age children are more likely to believe that they somehow were the cause of their sibling's death, not their parents.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-7 Question 12 Type: MCSA The nurse is having difficulty coping with the impending death of a child. Which would most likely be the best resource for the nurse at this time?

1. Co-workers 2. Hospice nurses 3. Unit manager 4. Spouse Correct Answer: 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Co-workers will also have a difficult time with the death.

Rationale 2: Mentorship with experienced hospice nurses as well as additional educational experiences could help promote professional nursing care.

Rationale 3: The unit manager also might have a difficult time with the impending death.

Rationale 4: The spouse might not fully understand why this is affecting the nurse.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-8 Question 13 Type: MCSA A woman gives birth to a stillborn infant. It is the policy of the maternity unit to create a memory box for parents of a fetal demise. Without parental permission, the nurse should avoid which intervention?

1. Making a plaster cast of the infant’s foot 2. Placing the blanket the baby was wrapped in into the memory box 3. Making hand- and footprints of the infant 4. Clipping a lock of hair to include in the memory box Correct Answer: 4 Rationale 1: This activity is not restricted by religious or cultural beliefs.

Rationale 2: This will give the parents something tangible to touch and hold. It is appropriate.

Rationale 3: These are appropriate.

Rationale 4: Some cultures prohibit removing anything from the body.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-2 Question 14 Type: MCSA The mother of a dying three-year-old child posts on Facebook: “Family and friends. Michael’s heart is giving out.

Looks like it will be tonight. He is surrounded by family and not in pain. I treasure every minute of being his mother. Pray for us.” The nurse who has worked with the family recognizes that Michael’s mother is in which stage of grieving according to Kubler-Ross?

1. Denial 2. Acceptance 3. Bargaining 4. Depression Correct Answer: 2 Rationale 1: The mother recognizes that death is near and is accepting of it.

Rationale 2: The mother has come to terms with her loss.

Rationale 3: The request for prayer is not an example of bargaining. In her acceptance of her child’s impending death, she is including her religious beliefs as a support.

Rationale 4: There is sadness in her message, but the overall message is one of acceptance.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-7 Question 15 Type: MCSA The nurse is doing a follow-up home visit to a family who lost their three-month-old infant to SIDS eight weeks ago. The mother answers the door in her nightgown with hair uncombed. During the interview, the mother states: “I don’t see the point of getting dressed each day.” The nurse recognizes that the mother is demonstrating which stage of grief behavior?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Recovery 2. Yearning, pining 3. Hostile 4. Disorganization Correct Answer: 4 Rationale 1: Recovery or acceptance is the stage when the person starts to reach out to others. This mother is not there.

Rationale 2: In this stage of grief behavior, the mother would be making statements such as, “If only…” or “what if ….”

Rationale 3: The mother is not expressing any hostile feelings.

Rationale 4: Disorganization or despair is a period of sadness and lethargy. Daily activities seem pointless during this stage.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-6 Question 16 Type: MCSA The nurse is leading a recovery group made up of parents who have lost a child. As the opening topic for the night’s discussion, the nurse has again reviewed information about the grief process to the parents and talked about how different people grieve. During the discussion phase, several fathers speak. The nurse recognizes that the father who needs more time to understand the grief process is the father who says: 1. “I understand that everyone grieves differently.”

2. “Looking back, I realize why I became so angry when the doctors didn’t cure my daughter.”

3. “It’s been six months since my son died, so why isn’t my wife ready to move on with our lives?”

4. “I’m glad you described some common grief reactions. I thought I was going crazy for a while.”

Correct Answer: 3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: This statement is accurate. This father understands this concept correctly.

Rationale 2: Anger is a part of the grief process. This father has been able to look at his own behavior and recognize it as normal.

Rationale 3: There is no standard period of grief. It is individual. This father has not heard the nurse’s discussion.

Rationale 4: This father has applied the knowledge of grief behaviors to his own behavior. He understands the discussion.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18-7 Question 17 Type: MCSA A child’s understanding of death changes as the child matures. When describing the adolescent’s understanding of death, which of the following concepts puts the adolescent at risk for driving under the influence (drunk driving) accidents?

1. A sense of invincibility 2. The idea that death is universal 3. The understanding that death is permanent 4. An understanding that death has an effect on survivors Correct Answer: 1 Rationale 1: While adolescents can recognize that death happens to everyone, even themselves, they often feel invincible; this leads to risk-taking behavior.

Rationale 2: This concept does not lead to risk-taking behavior.

Rationale 3: The adolescent recognizes that death is permanent, but this concept does not lead to risk-taking behavior.

Rationale 4: This concept does not lead to risk-taking behavior.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-1 Question 18 Type: MCSA The nurse is performing post-mortem care for a child of the Hindu faith. In the process of removing medical equipment, intravenous lines, and urinary catheters, the nurse discovers a thread wrapped around the child’s neck.

The nurse should: 1. Report this finding to social services as a possible act of child abuse.

2. Assume the thread became wrapped around the neck during the unsuccessful resuscitation effort and remove it.

3. Remove the thread for safe keeping and return it to the family with the child’s other possessions.

4. Leave the thread in place.

Correct Answer: 4 Rationale 1: In the Hindu faith, this thread indicates a blessing for the child.

Rationale 2: The nurse needs to consider the religious beliefs of this child before taking any action.

Rationale 3: The thread should not be removed; in the Hindu faith, the thread is a sign of blessing.

Rationale 4: The nurse should recognize that the thread wrapped around the neck or wrist is a blessing in the Hindu religion and should leave the thread in place.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-2 Question 19 Type: MCMA The hospital unit is very busy and nursing is understaffed. The nurse recognizes that death is imminent in one of her assigned patients. Nursing behaviors to offer family support would include: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Standard Text: Select all that apply.

1. Using active listening techniques when in the child’s hospital room.

2. Sitting in the room as time permits and looking the parents in the eye.

3. Avoiding tears in the child’s room.

4. Offering to call and notify family.

5. Recognizing that these parents’ needs are greater than the other patients and staying with the parents.

Correct Answer: 1,2,4 Rationale 1: Active listening encourages the parents to talk if they feel the need.

Rationale 2: This behavior indicates willingness to listen.

Rationale 3: This is no longer considered inappropriate and allows the parents to know that the nurse feels sadness at the loss.

Rationale 4: This would be appropriate and helpful to the parents.

Rationale 5: This is inappropriate as well as unsafe behavior. Although the nurse may want to stay with the parents, the other patients have needs as well.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-7

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Ball, Child Health Nursing, 3/E Chapter 19 Question 1 Type: MCSA 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 four to six months old.

2. Begin diluted fruit juice at two months of age, but wait three to five days before trying a new food.

3. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after two months of age.

4. Delay supplemental foods until the infant reaches 15 pounds or greater.

Correct Answer: 1 Rationale 1: Age four to six months is the optimal age to begin supplemental feedings. The infant does not need supplemental foods earlier, and introducing supplemental foods earlier does not promote sleep.

Rationale 2: Fruit juice and rice cereal are not well tolerated by infants at two months of age, as they lack the digestive enzymes to take in and metabolize many food products.

Rationale 3: Fruit juice and rice cereal are not well tolerated by infants at two months of age, as they lack the digestive enzymes to take in and metabolize many food products. Introducing cereal at this stage will not help promote sleep.

Rationale 4: Earlier feeding of nonformula foods, regardless of the infant's weight, is more likely to cause the development of food allergies.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-1 Question 2 Type: MCSA A nurse is talking to the mother of an exclusively breastfed, African American infant who is three months old and was born in late fall. The nurse would want to make sure that this child is receiving: 1. Iron 2. Vitamin D Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Calcium 4. Fluoride Correct Answer: 2 Rationale 1: An infant's iron stores are usually adequate until about four to six months of age.

Rationale 2: This infant will have limited exposure to sunlight due to decreased sun exposure in the fall and winter months. The limited sun exposure combined with the infant’s dark skin means the infant may need additional vitamin D. Rationale 3: The infant should be receiving sufficient amounts of calcium from breast milk.

Rationale 4: Fluoride supplementation, if needed, does not begin until the child is approximately six months old.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19-1 Question 3 Type: MCSA While teaching parents of a newborn about normal growth and development, the nurse informs them that their child's weight should: 1. Triple by nine months of age.

2. Double by five months of age.

3. Triple by six months of age.

4. Double by one year of age.

Correct Answer: 2 Rationale 1: The normal infant triples his birth weight by one year of age.

Rationale 2: It is expected that the infant would double in weight by five months of age.

Rationale 3: The child should double his birth weight by five months. A child whose weight triples by six months of age has gained weight too rapidly.

Rationale 4: The child should triple his birth weight by one year. This child may not be growing adequately.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-1 Question 4 Type: MCSA The nurse is teaching the parents of a four-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feedings 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. Aspiration.

2. Otitis media.

3. Malocclusion problems.

4. Sleeping disorders.

Correct Answer: 2 Rationale 1: There have been limited data to date showing a positive correlation to bottle propping and increased risk of aspiration.

Rationale 2: The infant’s Eustachian tube, which connects the throat to the middle ear, is shorter and straighter than an adult’s. When babies lie flat to feed, milk can easily enter the middle ear and increase the risk for otitis media.

Rationale 3: The primary concerns related to bottle propping are dental caries and otitis media. Poor dental alignment is not a significant problem.

Rationale 4: Sleeping disorders have not been found to be related to bottle propping.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-1 Question 5 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

An adolescent who is a vegetarian has been placed on iron supplementation secondary to a diagnosis of irondeficiency anemia. To increase the absorption of iron, the nurse would instruct the teen to take the supplement with: 1. Orange juice.

2. Black or green tea.

3. Milk.

4. Tomato juice.

Correct Answer: 1 Rationale 1: Acidity increases absorption of iron.

Rationale 2: Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Rationale 3: Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Rationale 4: Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-2 Question 6 Type: MCSA The nurse is presenting a program on healthy eating habits to the parents of children attending the clinic. In the discussion period of the program, parents make the following comments. Which parent needs more information about safe food preparation?

1. "We always wash our hands well before any food preparation."

2. "We use separate utensils for preparing raw meat and for preparing fruits, vegetables, and other foods."

3. "We take the meat out of the freezer and then allow it to thaw on the counter for two to three hours before cooking it thoroughly."

4. “If our baby doesn’t drink all the formula in his bottle, we throw the rest out.”

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: Washing hands removes pathogens from the hands and prevents food contamination.

Rationale 2: Raw meats are a good source of pathogens. Utensils used on raw meat can transfer the pathogens to other foods if they are not prepared in a manner to destroy these pathogens.

Rationale 3: 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.

Rationale 4: While drinking from a bottle, organisms can be transferred from the baby’s mouth to the formula. If this formula is saved, the organisms can multiply in the formula.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 19-4 Question 7 Type: MCSA During a four-month-old infant's well-child checkup, the nurse discusses introduction of solid foods into the infant's diet. Although the nurse recommends delaying the introduction of many foods into the diet, which food(s) will the nurse discuss delaying because they increase the risk for food allergy?

1. Honey 2. Carrots, beets, and spinach 3. Pork 4. Cow’s milk, eggs, and peanuts Correct Answer: 4 Rationale 1: Although honey can contain botulism spores that cannot be detoxified by the infant younger than one year old, it does not cause an allergic reaction.

Rationale 2: Carrots, beets, and spinach contain nitrates and should not be given before four months of age.

Rationale 3: The addition of pork is delayed until the infant is 8 to 10 months because meats are hard to digest.

Rationale 4: Cow’s milk, eggs, and peanuts are foods that have been associated with food allergies.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-4 Question 8 Type: MCMA The parents of a two-and-a-half-year-old are concerned about their child's finicky eating habits. While counseling the parents, which statements by the nurse would be accurate?

Standard Text: Select all that apply.

1. "Nutritious foods should be made available at all times of the day so that the child is able to 'graze' whenever he is hungry."

2. "The child is experiencing physiologic anorexia, which is normal for this age group."

3. "A general guideline for food quantity at a meal is one-quarter cup of each food per year of age."

4. "It is more appropriate to assess a toddler's nutritional demands over a one-week period rather than a 24-hour one."

5. "The toddler should drink sixteen to twenty-four ounces of milk daily."

Correct Answer: 2,4,5 Rationale 1: Food should be offered only at meal and snack times.

Rationale 2: Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age.

Rationale 3: The correct general guideline for food quantity is 1 tablespoon of each food per year of age.

Rationale 4: 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.

Rationale 5: Two to three cups of milk per day are sufficient for a toddler; 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 19-4 Question 9 Type: MCSA A six-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. Anaphylaxis.

3. Diarrhea.

4. Headache.

Correct Answer: 2 Rationale 1: Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Rationale 2: The child who also has asthma is at greatest risk for death secondary to anaphylaxis caused by a food allergy.

Rationale 3: Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Rationale 4: Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-5 Question 10 Type: MCSA 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 25th to 50th percentile for her age. Based on these findings, which disorder would the nurse suspect?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Anorexia nervosa 2. Bulimia nervosa 3. Marasmus 4. Kwashiorkor Correct Answer: 2 Rationale 1: Anorexia nervosa is an eating disorder where individuals literally starve themselves to prevent weight gain and also exercise excessively and use laxatives and diuretics to lose weight. Anorexia usually manifests as extreme weight loss and an obsession with food.

Rationale 2: The erosion of the tooth enamel and the presence of 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.

Rationale 3: Marasmus is a lack of energy-producing calories that can be seen in anorexia; it causes emaciation, decreased energy levels, and retarded development.

Rationale 4: Kwashiorkor is a protein deficiency, usually from malnutrition, that manifests as generalized edema.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-5 Question 11 Type: MCSA A six-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. Vitamin K. 2. Riboflavin.

3. Vitamin B12.

4. Thiamin.

Correct Answer: 1 Rationale 1: Vitamin K is fat soluble, as are A, D, and E. Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: Riboflavin, vitamin B12, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Rationale 3: Riboflavin, vitamin B12, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Rationale 4: Riboflavin, vitamin B12, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-5 Question 12 Type: MCMA The mother of a six-week-old infant tells the nurse that her baby has had colic for several days, crying for up to three hours and drawing his legs up on his abdomen. The mother says she is at “wits end” and wonders what she can do. The nurse learns that the infant is formula fed and gaining weight satisfactorily. The nurse would recommend: Standard Text: Select all that apply.

1. Breastfeeding the infant.

2. Switching to a bottle that has a collapsible bag inside.

3. Putting the infant in a baby swing after feeding.

4. Burping the baby more frequently.

5. Giving the baby a suppository once each morning.

Correct Answer: 2,3,4 Rationale 1: The infant is six weeks old. Initiating breastfeeding is not a good option at this time.

Rationale 2: This would reduce the amount of air that the baby swallows.

Rationale 3: The motion may reduce the abdominal discomfort.

Rationale 4: This helps the infant expel gas, which is a factor contributing to colic.

Rationale 5: Suppositories would not be recommended.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-2 Question 13 Type: MCSA A 14-year-old girl is being admitted to the eating disorders unit of the hospital. The girl has a two-year history of anorexia nervosa and recently has sustained additional weight loss and electrolyte imbalances. During hospitalization, the priority concern for the health care team will be: 1. Individual counseling.

2. Family therapy.

3. Regulation of antidepressant drugs.

4. Nutritional support.

Correct Answer: 4 Rationale 1: This will be an important component of inpatient treatment but is not the priority intervention.

Rationale 2: Family therapy is usually a component of the treatment of anorexia nervosa but is not the priority intervention.

Rationale 3: Antidepressant drugs may be used as a component of the treatment, but this is not the priority intervention.

Rationale 4: Hospitalization usually is in response to the weight loss and electrolyte imbalances, so nutritional support becomes the priority intervention. All other activities can be managed as outpatient therapies.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19-6 Question 14 Type: MCMA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

A two-month-old infant is admitted to the hospital with a diagnosis of “failure to thrive” (FTT). The nurse recognizes that the infant will be evaluated for: Standard Text: Select all that apply.

1. Over-dilution of formula concentrate.

2. Parental neglect.

3. Rumination.

4. Malabsorption syndromes.

5. Pica Correct Answer: 1,2,3,4 Rationale 1: Adding too much water to formula concentrate will lead to inadequate caloric intake and could lead to a diagnosis of FTT. Rationale 2: Parental neglect should be evaluated in a baby that is not gaining weight adequately.

Rationale 3: Rumination involves regurgitation of recently ingested food followed by re-chewing and reswallowing. It is often associated with sensory deprivation and may result in growth failure.

Rationale 4: Malabsorption syndromes, such as cystic fibrosis, can cause nutrients to be excreted instead of absorbed.

Rationale 5: Pica is an eating disorder characterized by ingestion of nonfood items. It would not be an issue in a two-month-old infant.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-4 Question 15 Type: MCMA A two-year-old child is admitted to the hospital for chronic diarrhea. After investigation, the child is diagnosed with celiac disease. The nurse teaches the family to avoid all glutens and to carefully read all labels. In evaluating the parents’ understanding, the nurse allows the family to complete the child’s menus. The nurse recognizes the family understands glutens when they choose which foods?

Standard Text: Select all that apply.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Milk 2. Mashed potatoes with gravy 3. Apple sauce 4. Corn in cream sauce 5. Rice cakes Correct Answer: 1,3 Rationale 1: Milk is a protein and contains no glutens.

Rationale 2: Gravy is made with flour. Unless the parents know the source of the flour, gravy should be avoided.

Most types of gravy contain wheat.

Rationale 3: All fruits are gluten free.

Rationale 4: Corn is acceptable. Cream sauce will probably have a vegetable protein as a filler.

Rationale 5: There are some brands of rice cakes that are gluten-free, but without reading the label, these should be avoided.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-5 Question 16 Type: FIB A premature infant is being tube fed. The physician ordered the feeding to total 120 kcal/kg/day. The infant weighs 1.86 kg. The formula contains 20 kcal per ounce. How many ounces of formula should the infant receive per day? Round your answer to the hundredth.

Standard Text: Correct Answer: 11.16 Rationale : 1.86 kg ×120 kcal/day = 223.2 kcal/day. 223.2 kcal divided by 20 kcal/ounce = 11.16 ounces Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-5

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Ball, Child Health Nursing, 3/E Chapter 20 Question 1 Type: MCSA A concerned parent calls the school nurse because of changes in his 15-year-old's behavior. Which behaviors would the nurse identify as most likely to be abnormal and indicate possible substance abuse in an adolescent?

1. 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 2. Becoming moody, crying, and weeping one minute and then cheerful and excited the next 3. Receiving numerous detentions lately from teachers for sleeping in class 4. Buying baggy, oversized clothing at thrift shops and dyeing her hair black Correct Answer: 3 Rationale 1: Periodically distancing themselves from their parents and preferring involvement with their peers are normal adolescent behaviors.

Rationale 2: Mood swings are normal adolescent behaviors.

Rationale 3: Even though most teens do prefer staying up late, they are not usually so tired that they 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.

Rationale 4: Experimenting with clothes and hair is a normal adolescent behavior.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-3 Question 2 Type: MCSA During a well-child exam, the parents of a four-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: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. "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."

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. "Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children."

Correct Answer: 4 Rationale 1: This information 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; the child will most likely be watching much more than two hours per day.

Rationale 2: This statement might encourage the parents to allow the child to watch more television, and the child's developmental need for physical activity is greater than the benefit that he might obtain by watching educational programs.

Rationale 3: This statement does not give parents a rationale, and it might seem opinionated to them.

Rationale 4: 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 evidence-based rationale for not placing a television in the child's room.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-1 Question 3 Type: MCSA 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. "Spend time with your children, and take cues from them about how much they want to discuss."

2. "Allow the children to watch as much television as they want. This is how they are coping with their father's absence."

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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. "It will just take some time to adjust to their father's absence and then everything will return to normal."

Correct Answer: 1 Rationale 1: Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase.

Rationale 2: Constant viewing of the TV coverage of the war might increase the children's anxiety and fear for their father's safety.

Rationale 3: Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase.

Rationale 4: The mother should be aware that even though the children might appear to have adjusted, there could be delayed reactions or regressions in behavior.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-1 Question 4 Type: MCSA A seven-year-old child has been seen in the pediatric clinic three times in the last two months for complaints of abdominal pain. On each occasion, the physical exam and all ordered lab work have been normal. The most important information to assess at this time would be: 1. The child’s normal eating habits.

2. Recent viral illnesses or other infectious symptoms.

3. Review of the child’s immunization history.

4. Changes in school or home life.

Correct Answer: 4 Rationale 1: Because of the abdominal complaints, the child’s eating habits would have already been discussed.

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Rationale 2: With normal blood work and tests, the chance of any illness over the last few months is unlikely.

Rationale 3: Rationale 4: 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. Asking about changes in home or school life is most likely to get to information about recent stresses in the child's life.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-1 Question 5 Type: MCSA 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 will get a job and somewhere to live.

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 are most likely to have unprotected sex.

Correct Answer: 4 Rationale 1: 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.

Rationale 2: Homeless teens are less likely to seek help when needed, frequently because of mistrust of others.

Rationale 3: Homeless teens are generally fearful and distrustful of authority figures.

Rationale 4: Teens who are homeless are more likely to engage in risky behaviors, 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.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-3 Question 6 Type: MCSA A parent is concerned about her eight-year-old 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 could be a response to: 1. Bullying.

2. Normal behavior for the age.

3. Lead poisoning.

4. Drug abuse.

Correct Answer: 1 Rationale 1: Physical complaints, suicidal thoughts, and other problems can result from bullying.

Rationale 2: The behaviors described in the stem are not normal behaviors for a child and need to be investigated.

Rationale 3: Lead poisoning can lead to physical symptoms, including neurologic deficits, but would not include the signs of emotional distress that the child is exhibiting.

Rationale 4: Drug abuse is more likely to occur in an adolescent than a child of this age.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Question 7 Type: MCSA A high school student calls to ask the nurse for advice on how to care for a new navel piercing. How should the nurse respond?

1. "Avoid contact with another person's bodily fluids until the area is well healed."

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2. "Do not move or turn the jewelry for the first three days."

3. "Apply lotion to the area, rubbing gently, to prevent skin from becoming dry and irritated."

4. "Apply warm soaks to the area for the first two days to minimize swelling."

Correct Answer: 1 Rationale 1: 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.

Rationale 2: The jewelry needs to be gently rotated several times per day to aid with healing.

Rationale 3: Lotion can provide a medium for bacteria, and rubbing at the site can cause irritation to the area.

Rationale 4: Ice, not warm soaks, should be applied to the area for the first two days to minimize the swelling.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-2 Question 8 Type: MCSA The school nurse is planning a smoking prevention program for middle school students. All of the following activities will be utilized. Which is likely to be the most effective in preventing middle school children from smoking?

1. A demonstration of the pathophysiology of the effects of smoking tobacco on the body given by the school’s biology teacher 2. A talk on the importance of not smoking given by a local high school basketball star 3. Colorful posters with catchy slogans displayed throughout the school 4. A pledge campaign during which students sign contracts saying that they will not use tobacco products Correct Answer: 2 Rationale 1: A physical demonstration may help the children recognize the long-term effects of smoking, but information from adults is not likely to influence children of this age more than the pressure of their peers will.

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Rationale 2: While all of the strategies are good, the most effective 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.

Rationale 3: Information from posters is not likely to influence children of this age more than the pressure of their peers will.

Rationale 4: Information from signed contracts is not likely to influence children of this age more than the pressure of their peers will.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-3 Question 9 Type: MCSA 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. Try to keep the parent separated from the child as much as possible.

2. Explain to the child that the parent is causing the illness and that the health care team will prevent the child from being harmed 3. Carefully document parent-child interactions.

4. Confront the parent with concerns of possible abuse.

Correct Answer: 3 Rationale 1: Separating the parent from the child might alienate the parent and cause her to leave with the child.

Rationale 2: Talking to the child about the healthcare team's suspicions could be confusing and frightening for the child.

Rationale 3: 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.

Rationale 4: Confronting the parent might alienate the parent and cause her to leave with the child.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-5 Question 10 Type: MCSA A young infant 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 was walking up the steps and slipped on the ice, falling while carrying my baby."

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 six-year-old brother was running through the house and tripped over the swing, causing it to fall."

4. "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."

Correct Answer: 2 Rationale 1: This statement is plausible from a developmental perspective.

Rationale 2: Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib.

Rationale 3: This statement is plausible from a developmental prospective.

Rationale 4: This statement is plausible from a developmental prospective.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Question 11 Type: MCSA

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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. Keeping all the guns put away and out of the child’s reach 2. Taking the child to a shooting range for lessons on how to use a gun properly 3. Storing the guns and ammunition in the same place 4. Using a gun lock on all firearms in the house Correct Answer: 4 Rationale 1: A 10-year-old child is able to reach any area of the house; more precautions need to be taken.

Rationale 2: Teaching gun safety is appropriate to a family that has guns, however, it is not sufficient to protect the child. The guns must be secured at all times the adults are not supervising the guns.

Rationale 3: It is recommended that guns and ammunitions be stored separately.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-5 Question 12 Type: MCSA While working at a weekend "free clinic," the nurse is assessing a three-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. Talking with the mother about keeping the child's ear clean by using a Q-tip 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. Providing the mother with samples of food and food stamps for the child Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. Giving the mother free samples of an antibiotic.

Correct Answer: 2 Rationale 1: Cleaning the ear with a Q-tip will not clear the ear infection.

Rationale 2: 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.

Rationale 3: The nurse will have neither food samples nor food stamps at her disposal.

Rationale 4: The course of treatment is usually 10 days. Free samples may not be for the appropriate antibiotic or be sufficient to treat the infection. A better intervention will be to provide help that will extend beyond the immediate period.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-6 Question 13 Type: MCMA The mother tells the nurse that her maternity leave is almost over and she will be returning to work soon. She will need to place her infant in a day care, and she asks the nurse how to know which day care is best. The nurse will tell the mother to investigate day care programs that: Standard Text: Select all that apply.

1. Are close to her work in the event of an emergency 2. Require all staff have criminal background checks 3. Are attractive in appearance, with bright colors and interesting visual stimulation 4. Provide regular training of the staff and administration 5. Have policies regarding child health and emergencies, such as immunization requirements and emergency medical forms Correct Answer: 2,4,5

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Rationale 1: This may be convenient and helpful, but it does not insure that the day care facility will provide quality care.

Rationale 2: This is a safety feature and provides some protection against child abuse and other incidents.

Rationale 3: Although this is valuable in a day care setting, it does not mean that the environment is safe or appropriate for the child.

Rationale 4: This information is appropriate as it provides information about the abilities of the staff to provide a safe and stimulating environment.

Rationale 5: This information identifies the school is prepared for emergency situations.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-2 Question 14 Type: MCMA The pediatric public health nurse visits a facility for the homeless. The nurse would evaluate the children staying at the facility for what type of medical/health issues?

Standard Text: Select all that apply.

1. Dental caries 2. Infections secondary to tattoos 3. Lack of immunizations 4. Nutritional deficits 5. Munchausen syndrome by proxy Correct Answer: 1,3,4 Rationale 1: Children who are homeless do not have the facilities or the supplies to care for their teeth and do not see a dentist on a regular basis.

Rationale 2: This is not a specific problem related to homelessness, and many states prohibit tattooing of children.

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Rationale 3: Homelessness often leads to lack of medical care, and some of the children may not be current on their immunizations.

Rationale 4: The family that is homeless often has difficulty with maintaining adequate nutrition.

Rationale 5: This is not a common problem for the homeless child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-6 Question 15 Type: MCMA A child is brought to the emergency department in a coma. The mother thinks the child may have ingested a poison. The nurse will assess: Standard Text: Select all that apply.

1. For burns around the mouth.

2. The child’s breath.

3. The child’s vomitus.

4. Hair samples.

5. Blood and urine toxicology screens.

Correct Answer: 1,2,3,5 Rationale 1: Corrosives often leave evidence of burns on the mouth and gums.

Rationale 2: The breath may have characteristic odors that may help identify the poison.

Rationale 3: The vomitus may contain leaves, indicating the child has eaten a plant or other items that may provide information on the toxin.

Rationale 4: Hair samples can be used to test drug use over a period of time. It would not contain any valuable information for this child.

Rationale 5: These tests will look for a wide variety of toxins.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-4 Question 16 Type: MCMA A child is admitted to the hospital with a diagnosis of lead poisoning. The health department nurse is investigating the child’s home to locate the source of the lead that the child has ingested. Which possibilities will the nurse investigate?

Standard Text: Select all that apply.

1. The home’s foundation for a possible radon leak 2. The home’s water pipes 3. The dirt surrounding the house 4. The presence of imported toys or antique baby furniture 5. Gas stored in cans Correct Answer: 2,3,4 Rationale 1: Radon is not a source of lead.

Rationale 2: Older water pipes were made from lead, which leaches out into the water.

Rationale 3: Children who eat dirt may acquire lead poisoning from eating dirt that has been coated with fumes from lead gas.

Rationale 4: Toys imported from other countries and old furniture may have lead paint. The child can be exposed if he puts his mouth on these objects.

Rationale 5: Most gas is now not lead-based. If the child were to drink the gas from the cans, the problem would be the hydrocarbons, not the lead.

Global Rationale: Cognitive Level: Analyzing Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-6 Question 17 Type: MCSA The child is admitted to the hospital unit for injuries. The mother’s boyfriend is suspected of child abuse. The nurse’s primary role, in addition to reporting to the proper authorities, is: 1. Gathering information about how the injuries occurred.

2. Collecting evidence against the suspected abuser.

3. Encouraging the child to talk about his experience.

4. Protecting the child from further injury.

Correct Answer: 4 Rationale 1: This is not a priority role for the nurse.

Rationale 2: This would be a police function, not the nurse’s responsibility.

Rationale 3: The nurse and the psychologist will be meeting with the child to help the child work through the experience, but this is not the priority action for the nurse.

Rationale 4: The nurse will monitor the child while in the presence of visitors. In addition, the nurse will talk with the social worker to assist in providing for the child’s safety in the future. This is a priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20-5 Question 18 Type: MCSA The school nurse in the high school recognizes that teenage pregnancy is a major problem in the school. The nurse recognizes that many high school girls hide their pregnancy to prevent adults from knowing they are pregnant.

Therefore, it is important that the nurse insure that all pregnant teenagers are aware of: 1. Safe haven laws.

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2. Birth control available to all teenagers.

3. Domestic abuse protection.

4. The father’s financial responsibility for the infant.

Correct Answer: 1 Rationale 1: Safe haven laws provide for unwanted babies to be left in certain locations without legal repercussions to the mother.

Rationale 2: A pregnant teenager does not need to know about birth control at this time.

Rationale 3: This is not the primary information that needs to be given to pregnant teenagers.

Rationale 4: Most teenagers are aware that the fathers are financially responsible. This is not information that is needed now.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20-6 Question 19 Type: MCSA A child is admitted for scald burns to his buttocks and thighs. According to the mother, she was preparing the child’s bath and before she could test the water, the child fell in and was scalded. The nurse would suspect child abuse because: 1. The burns are uneven, with some burns deeper than others.

2. The child’s hands and feet are free of burns.

3. In addition to the main burn site, there are splash burns surrounding the area.

4. The mother was home alone with the child.

Correct Answer: 2 Rationale 1: This might occur in an accidental scald burn.

Rationale 2: Someone who falls in hot water would immediately try to get out by using his hands and feet.

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Rationale 3: This would be a logical finding.

Rationale 4: It is not unusual for a mother to be home alone with a child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Question 20 Type: MCSA The nurse recognizes that the person guilty of child abuse may have which symptoms?

1. Physical illness 2. Alcoholism 3. Many friends and families nearby 4. Unrealistic expectations for their child 5. The abuser has no relationship to the child.

Correct Answer: 2,4 Rationale 1: This is not a common finding in abusers.

Rationale 2: Drug addiction and alcoholism are common findings in the abuser.

Rationale 3: The child abuser is often socially isolated.

Rationale 4: Abusive parents often feel the child is misbehaving for activities, such as soiling their diapers.

Rationale 5: Most abusers are parents or people who have contact with the child on a regular basis.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Chapter 21 Question 1 Type: MCSA The nurse is teaching the parents of a child with idiopathic rheumatoid arthritis about chronic pain. Which statement by the parent indicates teaching has been successful?

1. "When children have chronic pain, they may not have the same behavior as those in acute pain.”

2. "It is associated with a single event."

3. “Chronic pain can be managed successfully with NSAIDs.” 4. "It is sudden and of short duration."

Correct Answer: 1 Rationale 1: 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. Children with chronic pain do not show the physiological symptoms of pain that are associated with acute pain.

Rationale 2: Chronic pain is not associated with a single event.

Rationale 3: There are different levels of chronic pain just as there are different levels of acute pain.

Pharmacologic treatment will be based on the needs of the child, not the type of pain.

Rationale 4: Chronic pain is not sudden and short in duration.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 21-8 Question 2 Type: MCSA The postoperative unit of the pediatric hospital has several children who had surgery this morning. While making rounds, the nurse observes all of the following behaviors. Which child should be further evaluated as to postoperative pain?

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1. The six-month-old in deep sleep 2. The two-year-old who is cooperative when the nurse takes his vital signs 3. The four-year-old who is actively watching cartoons 4. The 14-month-old who is thrashing his arms and legs Correct Answer: 4 Rationale 1: Children are unable to obtain deep sleep when experiencing acute pain.

Rationale 2: When experiencing acute pain, children are less likely to cooperate with treatments.

Rationale 3: It is difficult for children to concentrate when experiencing acute pain.

Rationale 4: Young children in acute pain display a variety of behaviors, including loud crying, screaming, thrashing their arms and legs, lack of cooperation, clinging behavior, and restlessness and irritability.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-3 Question 3 Type: MCSA The nurse is taking care of a seven-year-old child who is postoperative. The child’s mother requests that the child not receive narcotics in the postoperative period because she is afraid the child will become addicted. The nurse would explain to the mother that children who do not receive adequate pain control will be at risk for: 1. Respiratory complications.

2. Urinary complications.

3. Cardiac complications.

4. Bowel complications.

Correct Answer: 1 Rationale 1: 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.

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Rationale 2: Uncontrolled pain does not usually lead to urinary complications.

Rationale 3: Uncontrolled pain does not lead to cardiac complications.

Rationale 4: Uncontrolled pain does not frequently lead to bowel complications.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-3 Question 4 Type: MCSA The nurse is caring for a two-year-old child in the postoperative period. The pain assessment tool most appropriate for assessment of pain intensity in a two-year-old is the: 1. Poker Chip Tool.

2. Oucher Scale.

3. Faces Pain Rating Scale.

4. FLACC Behavioral Pain Assessment Scale.

Correct Answer: 4 Rationale 1: The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.

Rationale 2: The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.

Rationale 3: The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.

Rationale 4: The FLACC scale is an appropriate tool for infants and young children who cannot report pain.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-4 Question 5 Type: MCSA A five-year-old is hospitalized with a fractured femur. Which assessment tool is appropriate for this child?

1. CRIES Scale 2. Faces Pain Rating Scale 3. SUN Scale 4. PIPP Scale Correct Answer: 2 Rationale 1: The CRIES Scale was developed for preterm and full-term neonates.

Rationale 2: A five-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level.

Rationale 3: The SUN Scale was developed for use in newborns.

Rationale 4: The PIPP Scale was developed for premature infants.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-4 Question 6 Type: MCSA 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. Reassess the child in 15 minutes to see if the pain rating has changed.

2. Administer the prescribed analgesic.

3. Do nothing, since the child appears to be resting.

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4. Ask the child's parents if they think the child is hurting.

Correct Answer: 2 Rationale 1: There is no need to reassess, as the child needs pain medication now.

Rationale 2: School-age children are old enough to report their pain level accurately. A pain score of six 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.

Rationale 3: The child might be lying quietly because movement increases the pain.

Rationale 4: The school-age child can answer for herself and does not need the parents to answer for her.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-3 Question 7 Type: MCSA A hospitalized three-year-old needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which is the most appropriate nursing diagnosis?

1. Knowledge deficit of the procedure 2. Fear related to the unfamiliar environment 3. Anxiety related to anticipated painful procedure 4. Ineffective individual coping related to an invasive procedure Correct Answer: 3 Rationale 1: The question stem indicates that the child has been through this before, so Knowledge deficit is not the most appropriate diagnosis.

Rationale 2: The child's fear is related not to the unfamiliar environment but to the anticipated pain of the IV stick.

Rationale 3: 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.

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Rationale 4: The child's behavior is appropriate for coping in this age child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21-7 Question 8 Type: MCSA 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 a period of time. While weaning, the nurse will observe the child for symptoms of too rapid withdrawal, including: 1. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps.

2. Bradycardia and pallor.

3. Decreased blood pressure and drowsiness.

4. Voracious appetite and hypotonicity.

Correct Answer: 1 Rationale 1: These are symptoms of withdrawal resulting from reducing the dose too quickly.

Rationale 2: A child who is being withdrawn from opioids too quickly will be tachycardic and have hot flashes and sweating.

Rationale 3: The child who is being withdrawn from opioids too quickly will be hypertensive and wakeful.

Rationale 4: Nausea, abdominal pain, diarrhea, and hypertonicity would be symptoms of withdrawal.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-5 Question 9 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

An analgesic is ordered for a post-surgical patient to be given every three to four hours. The nurse knows that a delay in giving the medication will cause a(n): 1. Decrease in the chance of withdrawal symptoms.

2. Decrease in the chance of addiction.

3. Increase in the chance of breakthrough pain.

4. Increase in the child's pain tolerance.

Correct Answer: 3 Rationale 1: A delay in giving pain medication will not decrease the chance of withdrawal symptoms if the medication is stopped without weaning.

Rationale 2: Delaying the pain medication will not decrease the chance of addiction.

Rationale 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.

Rationale 4: Delaying the pain medication will not increase the child's pain tolerance.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21-5 Question 10 Type: MCSA A parent asks the nurse if there is anything that can be done to reduce pain that his three-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. Use of guided imagery during the procedure.

3. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to the skin at least one hour prior to the procedure.

4. Use of muscle-relaxation techniques.

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Correct Answer: 3 Rationale 1: Sedation is not generally used with quick, minor procedures such as venipuncture.

Rationale 2: A three-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.

Rationale 3: EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Rationale 4: A three-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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-9 Question 11 Type: MCSA 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. Holding the infant.

2. Sucrose pacifier.

3. Massage.

4. Swaddling.

Correct Answer: 2 Rationale 1: Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress.

Rationale 2: Sucrose provides short-term, natural pain relief, and is most appropriate for use in neonates to decrease pain associated with a quick procedure.

Rationale 3: Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress.

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Rationale 4: Swaddling for a neonate undergoing a quick painful procedure will not decrease the pain.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21-6 Question 12 Type: MCSA A six-year-old postoperative patient IV has infiltrated and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. What other complementary therapies would be most helpful when placing this IV? 1. Restraints 2. Moderate sedation 3. Anesthesia 4. Distraction Correct Answer: 4 Rationale 1: Restraints are used only as a last resort and are not appropriate for an IV start.

Rationale 2: Moderate sedation has its own side effects and possible complications and should not be used for quick procedures.

Rationale 3: Drugs may not be used for quick procedures, such as a dressing change or an unexpected intravenous insertion, injection, or venipuncture.

Rationale 4: Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21-7 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 13 Type: MCSA A child who has chronic pain of long duration will exhibit which behavior?

1. Increased respiratory rate 2. Normal temperature 3. Normal heart rate 4. Decreased blood pressure Correct Answer: 3 Rationale 1: Chronic pain causes physiologic adaptation, so the respiratory rate likely will be normal.

Rationale 2: Body temperature is not a factor in chronic pain.

Rationale 3: 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.

Rationale 4: As the body adapts to chronic pain, the heart rate will be normal.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-8 Question 14 Type: MCSA The nurse is working in a pediatric surgical unit. The nurse would expect that patient-controlled analgesia would be most appropriate for which patient?

1. Twelve-year-old who is postoperative for spinal fusion for scoliosis 2. Ten-year-old who has a fractured femur and concussion from a bike accident 3. Five-year-old who is postoperative for tonsillectomy 4. Developmentally delayed 16-year-old who is postoperative for bone surgery.

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Correct Answer: 1 Rationale 1: Patient-controlled analgesia is most appropriate in children five 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.

Rationale 2: Children who have suffered head trauma would not be candidates for PCA. Rationale 3: PCA generally is prescribed for clients who will be hospitalized for at least 48 hours.

Rationale 4: Children who are developmentally delayed would not be candidates for PCA. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-5 Question 15 Type: MCSA A five-year-old child is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching?

1. "I will call the office tomorrow if the pain medicine is not relieving the pain."

2. "I can expect my child to have some pain for the next few days."

3. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow."

4. "I will plan to give my child pain medicine around the clock for the next day or so."

Correct Answer: 3 Rationale 1: If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified. This statement indicates the parent understands and does not need additional teaching.

Rationale 2: The child is expected to have some pain for a few days after surgery. This statement indicates the parent understands the teaching.

Rationale 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.

Rationale 4: The child should receive pain medication on a scheduled basis. This statement indicates the parent understands the teaching.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 21-7 Question 16 Type: MCSA The nurse is caring for a child who has been sedated for a painful procedure. What is the priority nursing activity for this child?

1. Place the child on a cardiac monitor.

2. Allow parents to stay with the child.

3. Monitor pulse oximetry.

4. Assess the child's respiratory effort.

Correct Answer: 4 Rationale 1: Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment.

Rationale 2: Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

Rationale 3: Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-10 Question 17 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The mother of a child who is recovering from surgery says to the nurse, “I don’t understand why that other nurse told me to stroke his forehead when he is in pain. Why will that make him feel better?” The nurse’s response will be based on the knowledge that: 1. Stroking the child’s forehead reminds the child of the mother’s continued presence, which is reassuring to the child.

2. Stroking causes a non-pain transmission to the brain that competes with the pain transmission and inhibits the pain message from reaching the brain.

3. Stroking causes the release of biochemicals, such as prostaglandins, which block pain transmission.

4. Stroking causes the release of endorphins, which reduce the perception of pain.

Correct Answer: 2 Rationale 1: While it is comforting to the child to have the mother present, this is not the reason that she has been instructed to stroke his forehead.

Rationale 2: This is the basis for gate control theory and is accurate.

Rationale 3: Prostaglandins and other biochemicals are the chemical pain messengers and trigger the nerve response.

Rationale 4: Endorphins are released in response to pain, not stroking.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-1 Question 18 Type: MCMA The nurse is caring for a four-year-old child who is intellectually disabled and is scheduled for surgery tomorrow.

The nurse wants to plan postoperative care and pain relief. The nurse will determine the best pain assessment tool by observing the child’s: Standard Text: Select all that apply.

1. Language skills.

2. Understanding of the concept of more and less or otherwise has the ability to quantify pain.

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3. Ability to sit for a ten minute evaluation.

4. Ability to perceive pain.

5. Ability to understand pain.

Correct Answer: 1,2 Rationale 1: In order to report pain, the child needs adequate verbalization skills to communicate to the nurse.

Rationale 2: The child who understands more or less can be given a three-option pain scale. The child who cannot understand more or less may need a behavioral pain scale.

Rationale 3: The assessment does not require the child to sit still.

Rationale 4: Children perceive pain. The issue is if the nurse can recognize the child’s pain.

Rationale 5: Children do not need to understand pain in order to feel pain.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-4 Question 19 Type: MCSA The nurse administered morphine intravenously to a four-year-old postoperative patient. Thirty minutes later, the nurse assesses the child. Which assessment finding requires further evaluation?

1. Pulse decreased from 136 to 104 2. Blood pressure dropped from 110/72 to 90/55 3. Respiratory rate went from 42 to 16 4. Child pulls away from nurse who wants to assess surgical site Correct Answer: 3 Rationale 1: The normal pulse rate for children two to five years of age is between 70 and 120.

Rationale 2: 90/55 is a normal finding for this age group.

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Rationale 3: This respiratory rate is on the low side for the age group and requires further evaluation to determine if the child’s respirations are being depressed.

Rationale 4: This is normal behavior for a four-year-old child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-7 Question 20 Type: FIB The physician has ordered the postoperative four-year-old child to receive hydromorphine (Dilaudid) intravenously. The drug book lists a therapeutic range for Dilaudid to be 0.01 to 0.015 mg/kg/dose every three to four hours. What would be the maximum therapeutic dose of Dilaudid if the child weighs 30 pounds? Round your answer to the nearest hundredth.

Standard Text: Correct Answer: 0.2 Rationale : Your answer should have a 0 in front of the decimal and no 0 after the 2. Otherwise, you may contribute to a medication error.

Global Rationale: Cognitive Level: Client Need: Client Need Sub: Nursing/Integrated Concepts: Learning Outcome: Question 21 Type: MCSA During shift report, the night nurse reports that the child who is terminally ill has developed tolerance to the morphine that the child has been receiving. The oncoming nurse realizes that the child: 1. Is physically dependent on morphine.

2. Is addicted to morphine.

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3. Is showing physical signs of withdrawal.

4. Will need more medication to achieve the same effect.

Correct Answer: 4 Rationale 1: While the child may be physically dependent, this is not the meaning of tolerance.

Rationale 2: Addiction refers to a compulsive use of a substance despite harm. This is not the definition of tolerance.

Rationale 3: Withdrawal occurs when the opioid is stopped suddenly. This is not the meaning of tolerance.

Rationale 4: Tolerance occurs when the body has become accustomed to the presence of the drug in the system.

When this happens, the child will need more of a drug or a stronger drug to get the same effect.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-2 Question 22 Type: MCSA The 17-month-old infant is terminally ill with cancer and is in constant pain. The nurse recognizes that the best way to control pain in this child would be for the physician to order: 1. Patient-controlled analgesia with the parents controlling the button that administers the dosage.

2. Intravenously administered opioids on a scheduled basis.

3. Intravenously administered opioids on a prn basis.

4. Parenteral administration controls pain more effectively than oral medication as oral absorption may be modified by stomach activities. In addition, providing analgesics on a scheduled basis is preferred over prn.

Correct Answer: 2 Rationale 1: PCA should always be controlled by the individual receiving the medication. It is inappropriate to have the parents control the medication administration.

Rationale 2: This provides continuous blood levels of the opioid.

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Rationale 3: By waiting until symptoms are present, the child’s blood level will drop, making it more difficult to control the pain.

Rationale 4: False Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21-5 Question 23 Type: MCMA The clinical nurse specialist is concerned about children’s reactions to painful invasive procedures such as intravenous starts. The nurse has decided to use distraction as a means to comfort the school-age child. Depending on the age of the school-age child, which technique might the nurse use to distract the child?

Standard Text: Select all that apply.

1. Blowing bubbles 2. Music therapy 3. Guided imagery 4. Hypnosis 5. Sucrose solution Correct Answer: 1,2,3 Rationale 1: Blowing bubbles or popping bubbles can be a distraction for a young school-age child.

Rationale 2: Listening to music or singing can be used as distraction for this age group.

Rationale 3: Guided imagery is a means of encouraging relaxation and mental images to manage pain.

Rationale 4: Under hypnosis, the child is an altered state of awareness; this is not a form of distraction.

Rationale 5: Sucrose solution is used for infants up to 12 months of age. It has not been found to be effective in the school-age child.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-7 Question 24 Type: MCMA In responding to the needs of pediatric patients in pain, the nurse has numerous nonpharmacologic interventions available. These interventions include: Standard Text: Select all that apply.

1. Regional nerve block.

2. Cutaneous stimulation.

3. Application of heat.

4. Electroanalgesia.

5. Use of EMLA cream.

Correct Answer: 2,3,4 Rationale 1: A regional nerve block involves injecting medications in an area that controls pain for a region of the body. It does not provide nonpharmacologic relief.

Rationale 2: Massage and rubbing of the skin as well as swaddling and kangaroo care are nonpharmacologic means of relieving pain.

Rationale 3: The use of heat (and cold) may help reduce pain sensations and utilizes no pharmacologic agents.

Rationale 4: Electrical stimulation to the skin uses the gate control theory to relieve pain.

Rationale 5: EMLA cream is a mixture of lidocaine and prilocaine that is applied to the intact skin. It is a pharmacologic pain relief method.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Chapter 22 Question 1 Type: MCSA 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. Low levels of antibodies.

2. High levels of maternal antibodies to diseases to which the mother has been exposed.

3. Passive transplacental immunity from maternal immunoglobulin G. 4. Been exposed to microorganisms during the birth process.

Correct Answer: 1 Rationale 1: The infant’s immune system is not fully developed at birth, and the infant has low levels of antibodies due to lack of exposure to antigens.

Rationale 2: 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.

Rationale 3: 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.

Rationale 4: Newborns and young infants do have exposure to microorganisms during the birth process, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-1 Question 2 Type: MCSA A nurse is providing education to a group of young mothers. The nurse would explain that as children grow, they develop immunity through:

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1. Immunization or exposure to the natural disease.

2. Acquiring diseases from family members who had the disease.

3. Acquiring diseases from other children.

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 increase their exposure to infectious agents.

Rationale 2: Children cannot acquire diseases from family members who had the disease Rationale 3: Acquiring disease from other children would not give children immunity.

Rationale 4: Newborns cannot be born with childhood disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-1 Question 3 Type: MCSA The nurse explains to new parents that as healthy children are exposed to more infections, they: 1. Naturally develop antibodies.

2. Are found to be healthier.

3. Will acquire terminal illnesses.

4. Will weaken their immune systems.

Correct Answer: 1 Rationale 1: As healthy children are exposed to more infections, they naturally develop antibodies.

Rationale 2: Being exposed to infections will not lead to healthy children.

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Rationale 3: Exposure to infections will not lead children to acquire terminal illnesses.

Rationale 4: Exposure to infectious disease will not weaken children's immune systems.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-1 Question 4 Type: MCSA 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 sitting together eating meals.

4. Children who are playing board games.

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.

Rationale 2: The fecal-oral and respiratory routes are the most common sources of transmission in children.

Rationale 3: Eating together will not transmit infectious disease.

Rationale 4: Playing with board games will not transmit infectious disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-2 Question 5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA The nurse is explaining the importance of hand washing after using the toilet to parents of young children. Which is the most important reason for this practice?

1. Children's immune systems are not fully developed.

2. Hand washing is the main way to limit the transmission of disease.

3. Not all bathrooms are clean.

4. Children do not like to have dirty hands.

Correct Answer: 2 Rationale 1: Underdeveloped immune systems will not transmit disease.

Rationale 2: The fecal-oral and respiratory routes are the most common sources of transmission in children.

Rationale 3: Children usually do not wash their hands after toileting unless they are closely supervised.

Rationale 4: This is not a reason for washing hands after using the toilet.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-2 Question 6 Type: MCSA 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. Proper hand hygiene 3. Keeping all toys clean and free from germs 4. Keeping child away from sick adults Correct Answer: 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: It is not possible to keep children free from colds.

Rationale 2: Proper hand hygiene is one of the most important health promotion strategies for all age groups of children as well as child care providers.

Rationale 3: Keeping all toys clean and free from germs is not possible.

Rationale 4: It is not always possible to keep children away from sick adults.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-2 Question 7 Type: MCSA 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. Toxoid 2. Antigen 3. Killed virus 4. Passive immunity Correct Answer: 4 Rationale 1: Toxoids are chemicals normally associated with a disease that stimulate the production of immunity.

Rationale 2: An antigen is any substance that causes the body to produce an antibody. In this situation, the goal is to provide the child with passive protection.

Rationale 3: The goal is to provide the child with immediate protection. Immunizations would lead to the development of immunity but would not provide immediate immunity.

Rationale 4: A child who has never had a tetanus immunization needs immediate protection (passive immunity) from tetanus. Passive immunity is made up of antibodies against the organism and provides immediate protection.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 8 Type: MCSA The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a six-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. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid 3. 22-gauge, 1/2-inch needle; IM (intramuscular); dorsogluteal 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. Rationale 2: Infants do not receive medication/vaccines in the deltoids.

Rationale 3: A 22-gauge needle is too big for infants, and injections should not be given in the dorsogluteal site.

Rationale 4: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8—3/4-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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22-4 Question 9 Type: MCSA 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: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Tell the mother that by not immunizing her child she may be exposing pregnant women to the virus, which could cause fetal harm.

2. Honor her request because she is the parent.

3. Tell the mother that she is wrong and should have her child immunized.

4. Explain the potential complications of measles, mumps, and rubella infections.

Correct Answer: 4 Rationale 1: This mother is not concerned about other women; she is concerned about what is best for her child.

Rationale 2: Nurses are responsible for helping parents make informed decisions. It is important that the mother has all the facts before she makes a decision.

Rationale 3: The mother has the right to make the decisions for her child. The nurse’s role is not to tell the parents what to do but to give them the information they need to make decisions.

Rationale 4: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct; measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 10 Type: MCSA The pediatric clinic has set a goal that 95% or more of the children attending the clinic will be fully immunized.

To reach this goal, clinic nurses will teach the families that: 1. The benefits of immunizations outweigh the risks of communicable diseases.

2. Immunizations should be completed by the time the child starts school.

3. Once a child receives a vaccination, that individual has lifelong immunity against that disease.

4. Vaccinations are 100% safe.

Correct Answer: 1 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: The risks and benefits of vaccines far outweigh the risks from communicable diseases and resulting complications.

Rationale 2: The immunization schedule is not completed by the time the child starts school. Immunizations continue throughout the life of the individual.

Rationale 3: It is important that the families realize that to be fully protected, many vaccinations will need to be repeated at specified times.

Rationale 4: Vaccinations can cause illness or injury. No medication is 100% safe.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 11 Type: MCSA A mother brings her four-month-old infant in for a routine checkup and vaccinations. The mother reports that the four-month-old was exposed to a brother who has the flu. In this case, the nurse will: 1. Withhold the DTaP vaccination but give the others as scheduled.

2. Give the infant the flu vaccination but withhold the others.

3. Give the vaccinations as scheduled.

4. Withhold the vaccinations.

Correct Answer: 3 Rationale 1: There is no reason to withhold any of the vaccinations due at this time.

Rationale 2: The flu vaccination would not routinely be given to a four-month-old.

Rationale 3: Giving the vaccine as scheduled will keep the infant properly immunized.

Rationale 4: Recent exposure to an infectious disease is not a reason to defer a vaccine.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 12 Type: MCSA Which should the nurse use when reconstituting vaccines?

1. The diluents provided 2. Normal saline 3. Any solution available 4. Sterile water Correct Answer: 1 Rationale 1: When reconstituting vaccines, it is important to use the solution provided and follow the manufacturer's directions.

Rationale 2: Not all medications are compatible with normal saline.

Rationale 3: Only use what is suggested by the manufacturer.

Rationale 4: Unless otherwise suggested, use what is suggested by the manufacturer.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22-5 Question 13 Type: MCSA A three-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. Tired.

2. Feverish.

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3. Flushed.

4. Toxic.

Correct Answer: 4 Rationale 1: The child might be tired, but this is not the best, most comprehensive description of the child's condition.

Rationale 2: The child has a high fever, but this is not the best, most comprehensive description of the child's condition.

Rationale 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.

Rationale 4: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-9 Question 14 Type: MCSA A parent reports that her five-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. Rubeola (measles).

2. German measles (rubella).

3. Chickenpox (varicella).

4. Fifth disease (erythema infectiosum).

Correct Answer: 4 Rationale 1: Children with rubeola have a high temperature and a blotchy maculopapular rash. Because there is a vaccination for rubeola, it is unlikely the child has it.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: The rash of rubella is a pink, maculopapular rash that begins on the face and progresses downward to the trunk and extremities. The child is fully vaccinated, making this unlikely.

Rationale 3: Varicella (chickenpox) and rubella (German measles) are unlikely if the child has had all recommended immunizations.

Rationale 4: Fifth disease manifests first with a flu-like 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-7 Question 15 Type: MCSA 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. Adult to child.

4. Person to insects.

Correct Answer: 2 Rationale 1: Some infectious diseases are transmitted by insects or animals and are not communicable from person to person.

Rationale 2: Some infectious diseases are transmitted by insects or animals and are not communicable from person to person.

Rationale 3: Some infectious diseases are transmitted by insects or animals and are not communicable from person to person.

Rationale 4: Zoonosis describes infectious diseases that are transmitted by animals and are not communicable from person to person.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-6 Question 16 Type: MCSA A two-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 ml three times daily by mouth for ten days for otitis media. To guard against antibiotic resistance, the nurse instructs the parent to: 1. Give the antibiotic for the full ten days.

2. Measure the prescribed dose in a household teaspoon.

3. Spread the dose evenly during daylight hours.

4. Stop the antibiotic when the child is afebrile.

Correct Answer: 1 Rationale 1: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria.

Rationale 2: A household teaspoon could contain less than 5 cc, and the full dose must be given.

Rationale 3: The antibiotic should be administered around the clock to maintain a blood level.

Rationale 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-7 Question 17 Type: MCSA 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: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).

2. 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.

3. Separating clients according to age and illness to prevent the spread of disease.

4. Disposing of blood-contaminated needles in the lead-lined container.

Correct Answer: 2 Rationale 1: Initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) is an appropriate nursing action but does not relate to terrorism.

Rationale 2: The CDC must be contacted to investigate the source of serious infections and to determine if a terrorist threat exists.

Rationale 3: Separating clients according to age will do nothing to stop terrorism.

Rationale 4: Proper disposal of blood-contaminated needles in the sharps container is appropriate nursing actions but does not relate to terrorism.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-7 Question 18 Type: MCSA 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. Rocky Mountain spotted fever and Lyme disease 2. Plague, anthrax, and smallpox 3. Rubella, mumps, and chickenpox 4. Severe acute respiratory syndrome (SARS) Correct Answer: 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Rocky Mountain spotted fever and Lyme disease are caused by ticks endemic to wooded areas.

Rationale 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.

Rationale 3: Rubella, mumps, and chickenpox are childhood communicable diseases that are not usually fatal.

Rationale 4: SARS is a rare infectious disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-7 Question 19 Type: MCSA The hospital admitting nurse is taking a history on a child's illness from the parents. The nurse concludes that the parents treated their six-year-old child appropriately for a fever related to otitis media when they report that they: 1. Put the child in a tub of cold water to reduce the fever.

2. Alternated acetaminophen with ibuprofen every two hours.

3. Offered generous amounts of fluids frequently.

4. Used aspirin every four hours to reduce the fever.

Correct Answer: 3 Rationale 1: Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Rationale 2: Alternating acetaminophen with ibuprofen every two hours could result in an overdose.

Rationale 3: The body's need for fluids increases during a febrile illness.

Rationale 4: Aspirin has been associated with Reye's syndrome and should not be given to children with a febrile illness unless prescribed by the physician.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22-8 Question 20 Type: MCSA 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. Sanitizing toys, telephones, and doorknobs to kill pathogens.

2. Teaching parents safe food preparation and storage.

3. Withholding immunizations for children with compromised immune systems.

4. Not separating children with infections from well children.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but it is not related to the flu virus.

Rationale 3: Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy.

Rationale 4: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-7 Question 21 Type: MCMA The mother of an immunocompromised child brings her child to the clinic for a routine check-up and recommended immunizations. The mother expresses concern that her child will “catch” the disease from the vaccination. The nurse would explain that which of the following carry no risk of acquiring the infection?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Standard Text: Select all that apply.

1. Toxoid 2. Killed virus vaccine 3. Live virus vaccine 4. Attenuated vaccine 5. Immunoglobulins Correct Answer: 1,2,5 Rationale 1: A toxoid is not an organism but a chemical produced by the organism. The toxoid has been treated to weaken its toxic effect.

Rationale 2: The immunization contains organisms that are dead and incapable of reproducing.

Rationale 3: This immunization contains live but weakened organisms. These organisms can mutate and reproduce and may cause disease in a weakened immune system.

Rationale 4: An attenuated vaccine is the same as a live virus vaccine.

Rationale 5: Immunoglobulins are the antibodies produced by others against a disease. They do not contain the live or killed virus.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 22 Type: MCMA The nurse is evaluating the immunization status of a child. The nurse recognizes that the child can acquire active immunity against a disease by: Standard Text: Select all that apply.

1. Receiving a dose of immunoglobulins.

2. Immunization with a killed virus vaccine.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Immunization with a toxoid.

4. Antibiotic therapy.

5. Acquiring the disease.

Correct Answer: 2,3,5 Rationale 1: Immunoglobulins provide passive immunity. No active immunity is acquired.

Rationale 2: This immunization will stimulate antibody production in the child which is active immunity.

Rationale 3: This immunization will also stimulate antibody production in the child.

Rationale 4: Antibiotic therapy provides no immunity.

Rationale 5: Having the disease will cause the body to develop antibodies against the organism which is active immunity.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-4 Question 23 Type: MCSA The nurse is preparing to administer a vaccine to a 14-month-old infant. Which finding would require that the nurse delay the vaccination until the next well-child visit?

1. The child is allergic to a substance in the vaccine.

2. The child has a low-grade fever and a runny nose.

3. The child received a dose of immune globulin two months ago.

4. The child is on antibiotics.

Correct Answer: 3 Rationale 1: This is a contraindication for this vaccine forever. The child should not receive the vaccine at the next well-child visit or at any other time.

Rationale 2: A mild upper respiratory infection would not be a contraindication for vaccine administration.

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Rationale 3: The antibodies in the immune globulin will prevent the child from developing immunity to the vaccination. By the next well-child visit, the immune globulins will not prevent immunity from developing.

Rationale 4: Antibiotic administration will not prevent the development of active immunity.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 24 Type: MCSA The clinic nurse is checking the potency of the vaccine. Which finding may have rendered the vaccine ineffective?

1. The vaccine was frozen as labeled.

2. The vaccines have been stored in a refrigerator where the temperature has been maintained between 35 ° to 46° F. 3. The vaccine’s expiration date expires within the next month.

4. The vaccine is stored in the door of the refrigerator.

Correct Answer: 4 Rationale 1: Some vaccines are stored in the freezer.

Rationale 2: This is appropriate to maintain potency.

Rationale 3: The vaccine is still effective until the expiration day.

Rationale 4: The door will not maintain the temperature of the vaccine. Vaccines should be stored in the middle of the refrigerator.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 25 Type: MCSA After her child receives a vaccination, the mother calls the clinic to report the child’s reaction to the immunization.

The nurse will recommend the mother call 911 when the mother reports: 1. A few hives are noted around the injection site.

2. The child is running a slight temperature.

3. The child has swelling of the face.

4. Fever and joint pains occurring within hours of the vaccination.

Correct Answer: 3 Rationale 1: This is a mild allergic reaction and does not require calling 911.

Rationale 2: A slight temperature does not require calling 911.

Rationale 3: This could be the onset of anaphylaxis, and immediate response is essential to the survival of the child. The mother should call 911.

Rationale 4: This is a common reaction to immunizations and does not indicate anaphylaxis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 26 Type: MCMA The nurse administers the flu vaccine to a school age child. After administering the vaccine, the nurse will document: Standard Text: Select all that apply.

1. The date of the last flu vaccine.

2. The site of the vaccination.

3. The lot and serial number of the vaccine.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. The date and time of administration.

5. Who assisted in restraining the child.

Correct Answer: 2,3,4 Rationale 1: This information is not pertinent.

Rationale 2: The site should be recorded.

Rationale 3: This information should be recorded in case a problem develops.

Rationale 4: This should be recorded.

Rationale 5: This information is not pertinent.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 27 Type: MCMA There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about disease at the school’s Parent Teacher Association meeting. The nurse explains that children cannot acquire vector-borne diseases from other children. The nurse explains that vector-borne diseases include: Standard Text: Select all that apply.

1. Measles (Rubeola).

2. Pertussis (whooping cough).

3. Rocky Mountain Spotted Fever.

4. West Nile Virus.

5. Lyme disease.

Correct Answer: 3,4,5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Rubeola is caused by a virus and is transmitted person to person.

Rationale 2: Pertussis is caused by a gram-positive coccobacilli called bordetella pertussis and is spread person to person.

Rationale 3: RMSF is a vector-borne disease spread by a tick.

Rationale 4: West Nile Virus is transmitted by a mosquito, a vector, and is not transmitted person to person.

Rationale 5: Lyme disease is also a vector-borne disease spread by a tick.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 28 Type: MCSA The school nurse wants to protect the students from Reye disease. To this end, the nurse creates a pamphlet that advises the parents to avoid giving which medication to a sick child?

1. Antibiotics 2. Acetaminophen 3. Ibuprofen 4. Aspirin Correct Answer: 4 Rationale 1: Antibiotics are not associated with Reye Disease.

Rationale 2: Acetaminophen is not associated with Reye Disease.

Rationale 3: Ibuprofen use is not associated with Reye Disease.

Rationale 4: Administering aspirin to a child with a viral illness has been found to be associated with Reye Syndrome.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-8

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Chapter 23 Question 1 Type: MCSA A four-year-old child is admitted to the hospital secondary to dehydration. Lab tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. This fluid loss is indicative of which condition?

1. Hypernatremia 2. Metabolic acidosis 3. Hypotonic dehydration 4. Isotonic dehydration Correct Answer: 3 Rationale 1: Hypernatremia is a condition where the body fluids are too concentrated and there is an excess of sodium.

Rationale 2: Metabolic acidosis refers to a condition where the pH of the blood is acidic.

Rationale 3: This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water.

Serum sodium is below normal levels. Hemoglobin and hematocrit will be high due to the loss of serum water.

Rationale 4: This occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-3 Question 2 Type: MCSA A nurse is taking care of four different pediatric clients. Which of the following children is at greatest risk for dehydration?

1. Seven-year-old child with migraine headaches Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Four-year-old child with a broken arm 3. Two-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea Correct Answer: 4 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.

Rationale 2: 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.

Rationale 3: 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.

Rationale 4: The pediatric client with the greatest risk is under two years of age and with a condition that increases insensible fluid loss.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-4 Question 3 Type: MCSA 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. Wearing dark clothing during exercise is recommended 2. Water is the drink of choice to replenish fluids.

3. During activity, stop for fluids every 15 to 20 minutes.

4. Hydration should occur at the end of an exercise session.

Correct Answer: 3 Rationale 1: Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: A combination of water and sports drinks is best to replace fluids during exercise.

Rationale 3: During activity, stopping for fluids every 15 to 20 minutes is recommended.

Rationale 4: Hydration should occur before and during the activity, not just at the end.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23-5 Question 4 Type: MCSA The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which other sign indicates the infant is still in the early to moderate stage of dehydration?

1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels Correct Answer: 2 Rationale 1: Bradycardia is not a sign of dehydration.

Rationale 2: Tachycardia is a sign that indicates moderate dehydration.

Rationale 3: In dehydration, the blood pressure is hypotensive.

Rationale 4: Fontanels would be sunken in moderate dehydration.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 5 Type: MCSA In the morning, a nurse receives a report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the nurse see first?

1. The child with tachypnea and pulmonary congestion 2. The child with hepatomegaly and normal respiratory rate 3. The child with dependent and sacral edema and regular pulse 4. The child with periorbital edema and normal respiratory rate Correct Answer: 1 Rationale 1: A child with respiratory distress should be the first client the nurse checks after receiving a report.

Rationale 2: The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

Rationale 3: The child with dependent and sacral edema and regular pulse is more stable than the child with tachypnea and pulmonary congestion.

Rationale 4: The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-5 Question 6 Type: MCSA The nurse is caring for a child on bed rest who has severe edema in a left lower leg due to blocked lymphatic drainage. Which nursing diagnosis would take priority?

1. Risk for impaired skin integrity 2. Risk for altered body image 3. Risk for imbalanced nutrition: less than body requirements Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. Risk for activity intolerance Correct Answer: 1 Rationale 1: The highest-priority problem is skin integrity.

Rationale 2: Body image would not take priority over the integrity of the skin for this scenario.

Rationale 3: Nutrition would not take priority over the integrity of the skin for this scenario.

Rationale 4: Activity intolerance would not take priority over the integrity of the skin for this scenario.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23-4 Question 7 Type: MCSA A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a licensed vocational nurse (LVN), cautions the LVN to watch for which clinical manifestation?

1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia Correct Answer: 1 Rationale 1: A child with hyponatremia is at risk for seizures.

Rationale 2: Respiratory distress is not a risk of hyponatremia.

Rationale 3: Hyperthermia is not a risk of hyponatremia.

Rationale 4: Bradycardia is not a risk of hyponatremia.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-4 Question 8 Type: MCSA A nurse is planning care for a child with hyperkalemia. The nurse explains to the parents that an adverse outcome of hyperkalemia is: 1. Hyperthermia 2. Respiratory distress 3. Seizures 4. Cardiac arrhythmias Correct Answer: 4 Rationale 1: Excessive potassium is unrelated to the body temperature.

Rationale 2: Potassium is needed for contractility of heart and skeletal muscles but not for the muscles of respiration.

Rationale 3: Seizures are not an adverse outcome of hyperkalemia.

Rationale 4: A child with hyperkalemia is at risk for cardiac problems that can be life-threatening, such as arrhythmias.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-4 Question 9 Type: MCSA 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. Metabolic alkalosis.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Metabolic acidosis.

3. Respiratory acidosis.

4. Respiratory alkalosis.

Correct Answer: 3 Rationale 1: Uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.

Rationale 2: Uncompensated metabolic acidosis has a decreased pH, normal pCO2, and normal HCO3.

Rationale 3: 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.

Rationale 4: Uncompensated respiratory alkalosis has an increased pH, decreased pCO2, and normal HCO3.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-4 Question 10 Type: MCSA 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. 0.9% normal saline (NS) 2. D5 0.2% (¼) normal saline 3. D5W 4. Albumin Correct Answer: 1 Rationale 1: 0.9% normal saline (NS) is an isotonic fluid and maintains Na and chloride at present levels.

Rationale 2: D5 0.2% (¼) normal saline would not be used initially but later, as maintenance fluids.

Rationale 3: D5W can lower sodium levels, and so it would not be used to replace fluids in severe isotonic dehydration.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: Albumin is used to restore plasma proteins.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 11 Type: MCSA A six-year-old child is hypokalemic. The nurse is helping the child complete the menu. The nurse would encourage this child to select which menu items?

1. Pizza with a fruit plate 2. Chicken strips with chips 3. Fajita with rice 4. A hamburger with French fries Correct Answer: 1 Rationale 1: 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.

Rationale 2: Chicken strips and chips are not good sources of potassium.

Rationale 3: The nurse is looking for potassium-rich foods that are attractive to children. This choice does not meet the requirement.

Rationale 4: A hamburger and French fries do not provide potassium.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 12 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give?

1. Furosemide (Lasix) 2. Hydrochlorothiazide (Aquazide) 3. Spironolactone (Aldactone) 4. Mannitol (Osmitrol) Correct Answer: 1 Rationale 1: Furosemide (Lasix) is the diuretic used to aid in excretion of calcium.

Rationale 2: Thiazide diuretics (like hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client.

Rationale 3: Spironolactone (Aldactone) is a potassium-sparing diuretic. While there is a net increase in calcium in the urine, it is not as effective an option as furosemide.

Rationale 4: Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-5 Question 13 Type: FIB 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 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

200 cc of D 51/2 sodium chloride IV Output: 345 cc of urine

50 cc of loose stool

How many milliliters should the nurse document as the client's total intake? Give numerical answer only. Do not include any units of measurement.

Standard Text: Correct Answer: 440 Rationale : The child takes in 120 ml of Pedialyte and 120 ml of Jell-O for a total of 240 ml. With 200 ml of IV fluids, the total intake is 440 ml.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 14 Type: MCSA 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, what should this child's hourly IV rate for 24 hours be?

1. 88 2. 86 3. 81 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. 83 Correct Answer: 2 Rationale 1: 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.

Rationale 2: 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.

Rationale 3: 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 15 Type: MCMA A nine-month-old infant is hospitalized with vomiting and diarrhea. The mother questions why her child needed hospitalization since her school-age nephew had the same symptoms and was treated at home. The nurse would explain that an infant is more at risk for dehydration than a school-age child because: Standard Text: Select all that apply.

1. Infants have a lower proportion of their body weight as water.

2. The percentage of extra-cellular fluid is higher in the infant than the school-age child.

3. School-age children have a larger body surface area.

4. The school-age child’s kidneys are more mature and better able to conserve water.

5. The metabolic rate of the school-age child is higher.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 2,4 Rationale 1: Infants have a higher percentage of body weight as water.

Rationale 2: This statement is accurate.

Rationale 3: Body surface area is an assessment of skin surface. BSA compares the height and weight of the child and is greatest in infancy.

Rationale 4: This statement is accurate.

Rationale 5: Infants have a higher metabolic rate than a school-age child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-1 Question 16 Type: MCSA As a result of opioid administration, a child’s respirations are slow and shallow. The nurse would expect that lab changes that might be noted in response to the changes in the child’s uncompensated respiratory pattern would include: 1. Increased PCO2 and respiratory acidosis.

2. Decreased PCO2 and respiratory alkalosis.

3. Low pH and low PCO2.

4. High pH and high PCO2.

Correct Answer: 1 Rationale 1: Due to inadequate respirations, the child retains CO2 and develops respiratory acidosis.

Rationale 2: This statement is incorrect as the child retains carbon dioxide.

Rationale 3: The pH would be acidic, but the pH would be high.

Rationale 4: The child would have a low pH (acidosis) and high PCO2.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-4 Question 17 Type: MCSA The nurse notes that the specific gravity of urine is lower in infants than in older children. The nurse recognizes that the rationale for this difference is related to: 1. The infant having a greater body surface area.

2. The infant having a higher basal metabolic rate.

3. The infant having a greater percentage of body weight that is water.

4. The infant’s kidneys being less able to concentrate urine.

Correct Answer: 4 Rationale 1: Although this is true, it does not explain the lower specific gravity.

Rationale 2: This statement is true but does not explain the specific gravity differences.

Rationale 3: Although the statement is true, it does not explain the specific gravity differences.

Rationale 4: This statement is accurate and explains why the specific gravity of the infant’s urine is closer to water than an older child’s urine specific gravity.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-2 Question 18 Type: MCSA The nurse is evaluating an infant for dehydration. Which assessment provides the most accurate information on dehydration?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Urine output 2. Urine specific gravity 3. The infant’s vital signs 4. Weight loss Correct Answer: 4 Rationale 1: The infant is unable to concentrate urine and will continue to void dilute urine.

Rationale 2: The infant’s kidney is immature and unable to concentrate urine.

Rationale 3: Pulse will elevate and blood pressure may drop, but the other vital sign findings will remain unchanged. However, this is not the best assessment of dehydration.

Rationale 4: Daily weights on an infant provide the most accurate assessment of fluid balance.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-4

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Ball, Child Health Nursing, 3/E Chapter 24 Question 1 Type: MCSA The nurse is caring for a young child with otitis media. The parent asks the nurse why children seem to get otitis media frequently but adults do not. The nurse would explain that younger children get otitis media more often because: 1. The eustachian tube is shorter, wider, and horizontal in younger children.

2. The eustachian tube is shorter, more narrow, and horizontal in younger children.

3. The eustachian tube is longer, wider, and vertical in younger children.

4. The eustachian tube is longer, more narrow, and vertical in younger children.

Correct Answer: 1 Rationale 1: The eustachian tube, which connects the nasopharynx to the middle ear, is proportionately shorter, wider, and more horizontal in infants and young children than in older children or adults. This promotes an increase in the incidence of ear infections.

Rationale 2: The eustachian tube, which connects the nasopharynx to the middle ear, is proportionately shorter, wider, and more horizontal in infants and younger children than in older children or adults. This promotes an increase in the incidence of ear infections.

Rationale 3: The eustachian tube, which connects the nasopharynx to the middle ear, is proportionately shorter, wider, and more horizontal in infants and younger children than in older children or adults. This promotes an increase in the incidence of ear infections.

Rationale 4: The eustachian tube, which connects the nasopharynx to the middle ear, is proportionately shorter, wider, and more horizontal in infants and younger children than in older children or adults. This promotes an increase in the incidence of ear infections.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-1 Question 2 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The nurse is caring for four clients in the neonatal intensive care unit. Which infant has the greatest risk of developing retinopathy of prematurity (ROP)?

1. 28-weeks'-gestation infant who has been on long-term oxygen and weighed 1,400 grams 2. 32-weeks'-gestation infant of African heritage with a congenital heart defect who needed no oxygen and weighed 1,850 grams 3. 28-weeks'-gestation female infant who was on short-term oxygen, weighed 1,420 grams, and was treated with phototherapy 4. 36-weeks'-gestation, small-for-gestational-age infant who was in an oxyhood for 12 hours and weighed 1,800 grams Correct Answer: 1 Rationale 1: 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 1,600 g), and oxygen therapy.

Rationale 2: The 32-weeks'-gestation infant was not placed on oxygen, and therefore is not at risk. Risk for developing retinopathy of prematurity is lower for infants of African heritage than Caucasian infants. Congenital heart defects are not associated with ROP. Rationale 3: The 28-weeks'-gestation infant was only placed on short-term oxygen. Phototherapy is associated with hyperbilirubinemia and is not associated with ROP. Rationale 4: The 36-weeks'-gestation infant was on oxygen for short period of time. A small-for-gestational-age baby would be more mature than an infant of the same weight but lower gestational age.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-2 Question 3 Type: MCSA The nurse is taking care of a child who had a tonsillectomy. During the postoperative period, the nurse should observe the child for which clinical manifestation?

1. Arrhythmias 2. Dehydration Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Increased blood sugar 4. Increased urinary output Correct Answer: 2 Rationale 1: Unless the child has a heart condition prior to surgery, arrhythmias is not a possible postoperative complication Rationale 2: 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.

Rationale 3: Increased blood sugar will result only if the child is a diabetic.

Rationale 4: Increased urinary output is not an expected complication of surgery.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-2 Question 4 Type: MCSA A neonate has been diagnosed with a herpes simplex viral infection of the eye. Which medication will the nurse prepare to administer?

1. Oral erythromycin 2. Fluoroquinolone eyedrops or ointment 3. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment 4. Intravenous penicillin Correct Answer: 3 Rationale 1: Oral erythromycin is used to treat Chlamydial eye infections.

Rationale 2: Fluoroquinolone eyedrops are used to treat bacterial eye infections.

Rationale 3: Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine).

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Rationale 4: Intravenous penicillin treats selected bacterial infections.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24-4 Question 5 Type: MCSA A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis would be appropriate for this child?

1. Self-care deficit 2. Impaired physical mobility 3. Impaired home maintenance 4. Delayed growth and development Correct Answer: 4 Rationale 1: Self-care deficit does not apply to this age of child.

Rationale 2: The child's mobility is not due to a physiological problem, so impaired mobility is not appropriate.

Rationale 3: There are not enough data to determine if home maintenance is impaired.

Rationale 4: A 20-month-old child who is not walking is delayed in growth and development. Toddlers generally walk by 15 months of age.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24-4 Question 6 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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. Taking the child on a tour of the unit.

4. Letting the child touch equipment that will be used during the hospitalization.

Correct Answer: 2 Rationale 1: Policies can be covered at a later time Rationale 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.

Rationale 3: Tours can be done at a later time.

Rationale 4: Handling equipment can be covered at a later time.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-4 Question 7 Type: MCSA 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 a decongestant.

3. Place the baby to sleep with a pacifier.

4. Administer acetaminophen (Tylenol) to relieve discomfort.

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: A flat position could exacerbate the discomfort. Elevating the head slightly is recommended.

Rationale 2: Decongestants are not recommended for treatment of acute otitis media.

Rationale 3: Placing infants to sleep with a pacifier can increase the incidence of otitis media.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-5 Question 8 Type: MCMA The nurse has taught a group of parents how to care for their children who have just had tympanostomy tubes inserted. The nurse will know the parents understand how to care for their child's tympanostomy tubes if they: Standard Text: Select all that apply.

1. Limit their diets to soft, bland foods.

2. Restrict the children to quiet activities after surgery.

3. Administer a decongestant for one to two weeks following surgery.

4. Encourage the children to drink generous amounts of fluids.

5. Avoid getting water in their ears during bath time.

Correct Answer: 2,4,5 Rationale 1: Limiting the diet to soft, bland foods and administering decongestants are not needed after surgery.

A regular diet should be resumed.

Rationale 2: 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.

Rationale 3: Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting their diets to soft, bland foods.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: 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.

Rationale 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24-5 Question 9 Type: MCSA The nurse can assist a child who has a mild hearing loss and reads lips to adapt to hospitalization by: 1. Touching the child lightly before speaking.

2. Using a picture board as the main means of communication.

3. Speaking in a loud voice while facing the child.

4. Speaking directly to the parents for communication.

Correct Answer: 1 Rationale 1: The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the child's visual attention by lightly touching the child before communicating.

Rationale 2: Picture boards, while useful, should not be the primary means of communication for a child who reads lips.

Rationale 3: Speaking in a loud voice might not promote hearing in the child.

Rationale 4: Speaking to only the parents does not help the child with the hospitalization.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 10 Type: MCSA A child has epistaxis while at school. The school nurse appropriately intervenes by: 1. Lying the child down and applying a warm pack.

2. Tilting the child's head back, squeezing the bridge of the nose, and applying a warm moist pack to the nose.

3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose.

4. Immediately packing the nares with a cotton ball soaked with Neo-Synephrine.

Correct Answer: 3 Rationale 1: Lying the child down would allow the blood to drain down the throat, which could lead to aspiration.

Warmth would promote the bleeding.

Rationale 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.

Rationale 3: 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.

Rationale 4: A cotton ball soaked with Neo-Synephrine would only be used if the bleeding did not stop with pressure and ice.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-5 Question 11 Type: MCSA The nurse has completed postoperative discharge teaching to the parents of a child who has had a tonsillectomy.

Which statement indicates the parents have understood the teaching?

1. "We will call the physician for any indication of ear pain."

2. "We will be sure to give our child adequate amounts of citrus juices."

3. "We will plan on administering acetaminophen (Tylenol) for pain."

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. "We will keep our child on bed rest for ten days after the surgery."

Correct Answer: 3 Rationale 1: Ear pain four to eight days after a tonsillectomy might be experienced and does not indicate an ear infection.

Rationale 2: Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation.

Rationale 3: Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy.

Rationale 4: Children do not need to be confined to bed. They can return to school in 10 days.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24-5 Question 12 Type: MCSA A nurse who is planning to teach school-age children about the "common cold" should include what information?

1. Aspirin should be taken for alleviation of fever if the common cold is contracted.

2. Antibiotics will eliminate the nasopharyngitis virus.

3. Vaccinations can prevent contraction of a nasopharyngitis virus.

4. Proper hand washing can prevent the spread of the common cold.

Correct Answer: 4 Rationale 1: Aspirin should not be taken for fever because of its association with Reye's syndrome.

Rationale 2: Antibiotics are not used to treat viral infections.

Rationale 3: No vaccine can prevent the common cold.

Rationale 4: Proper hand washing should be taught to school-age children to reduce the spread of the "common cold" virus.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24-6 Question 13 Type: MCSA The school nurse is screening all second graders for tonsillitis and pharyngitis. Which finding is a normal finding in this age group?

1. Tonsils are large and seem to fill the throat.

2. Child is complaining of sore throat and drooling 3. White patches are observed on the tonsils.

4. Throat appears red, and child has a low-grade fever Correct Answer: 1 Rationale 1: This is a normal finding as the tonsilar material grows faster than the child and reaches adult size in this age group. It is not a reason to refer the child for follow-up.

Rationale 2: Both symptoms indicate pharyngitis and should be evaluated by a physician.

Rationale 3: White exudate is associated with tonsillitis and requires further evaluation.

Rationale 4: These symptoms suggest pharyngitis; the child should be evaluated further.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-1 Question 14 Type: MCMA A 10-month-old infant has had numerous ear infections since birth. The nurse will discuss with the parents ways that might reduce the incidence of otitis media and will include which strategies?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Standard Text: Select all that apply.

1. Prohibiting tobacco smoke in the home 2. Avoiding use of a pacifier while the child is sleeping 3. Breastfeeding the infant 4. Cleaning the child’s ears nightly with peroxide 5. Avoiding use of wood-burning stoves Correct Answer: 1,2,5 Rationale 1: This has been shown to decrease the incidence of otitis media.

Rationale 2: The use of a pacifier for the sleeping baby has been associated with otitis media.

Rationale 3: While breastfeeding is associated with lower incidences of otitis media, this child is 10 months old.

Rationale 4: Otitis media is not prevented by cleaning the ears.

Rationale 5: Wood-burning stoves are associated with higher rates of otitis media.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-6 Question 15 Type: MCSA A three-year-old child has been found to have a mild to moderate hearing loss. The mother tells the nurse: “The doctor told me I should put my child in day care but didn’t tell me why. Do you know why the doctor recommends day care?” The nurse’s response will be based on the knowledge that day care will: 1. Help the child recognize his hearing deficit.

2. Increase the child’s socialization skills.

3. Improve the child’s immunity by increased exposure to organisms.

4. Teach other children that children are different.

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Correct Answer: 2 Rationale 1: This would not be a goal of treatment. The child is aware of what he hears but may not be aware of what he is not hearing.

Rationale 2: By increasing the interaction with other children, the hearing-impaired child will improve his socialization skills.

Rationale 3: Increased exposure to organisms will occur, but this is not the goal of the recommendation.

Rationale 4: The physician’s concern is the well-being of this child, not the other children.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24-4 Question 16 Type: MCSA While screening children, the nurse notes that one child seems to have “crossed eyes.” Which screening tool might the nurse utilize to further screen this child?

1. Examine the eye with an otoscope.

2. Check for the “red reflex” in the eyes.

3. Perform the cover-uncover test.

4. Use a tonometer to evaluate the eyes.

Correct Answer: 3 Rationale 1: An otoscope is used to examine the ear, not the eye.

Rationale 2: The red reflex visualizes the retina and is used to identify infants with cataracts.

Rationale 3: When one eye is covered while the child is looking at an object, the uncovered eye will deviate from the location; this tool is used to detect strabismus.

Rationale 4: The tonometer measures intraocular pressure and is used to evaluate glaucoma.

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Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-3 Question 17 Type: MCSA The nurse is reviewing discharge instructions for a child who has received a cochlear implant. In addition to encouraging speech therapy for the child, the nurse will instruct the parents to monitor the child for signs of: 1. Ringing in the ears.

2. Pharyngitis.

3. Hearing loss.

4. Bacterial meningitis.

Correct Answer: 4 Rationale 1: This is not a common complication of a cochlear implant.

Rationale 2: Pharyngitis is not associated with cochlear implants.

Rationale 3: The child already has hearing loss. That is why the child receives a cochlear implant.

Rationale 4: There is an increased risk of bacterial meningitis following insertion of a cochlear implant.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-4 Question 18 Type: MCMA Following a facial injury of a 12-year-old youth during a baseball game, a nurse speaks with the league administrators about first aid for teeth that may be lost. The nurse will instruct the administration that appropriate first aid will include: Standard Text: Select all that apply.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Not worrying about the tooth loss, as children this age still have their “baby” teeth.

2. Only handling the lost tooth by the roots and avoiding touching the crown of the tooth.

3. Rinsing the lost tooth with sterile saline.

4. Placing the tooth back into its socket and taking the child to an emergency dental facility.

5. Keeping the tooth clean and dry during transport to an emergency dental facility.

Correct Answer: 3,4 Rationale 1: By twelve years of age, children have their permanent teeth.

Rationale 2: First aid includes handling the tooth only by the crown and not touching the roots.

Rationale 3: This is appropriate, as there is hope that the tooth can be re-implanted.

Rationale 4: This is an appropriate way to manage the tooth.

Rationale 5: The tooth should be kept moist.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-6

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Ball, Child Health Nursing, 3/E Chapter 25 Question 1 Type: MCSA A toddler has had recurrent respiratory infections. The mother of the child expresses concern that her infant seems to be at increased risk for complications from respiratory infections in comparison with her older children. The best response from the nurse would be: 1. "You are incorrect in your assessment."

2. "The younger child’s airways are smaller and more easily occluded."

3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children."

4. "Toddlers do not breathe as deeply as do older children."

Correct Answer: 2 Rationale 1: The mother is correct in her statement.

Rationale 2: Airways are smaller in the younger child and are more easily occluded when mucus is produced.

Rationale 3: Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent.

Rationale 4: Depth of breathing is not age-dependent.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-1 Question 2 Type: MCSA A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). The nurse should be prepared to perform which intervention?

1. Administer antibiotics and assist with possible intubation.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Obtain a sputum specimen.

3. Swab the throat for a throat culture.

4. Administer nebulized epinephrine and oral or IM dexamethasone.

Correct Answer: 4 Rationale 1: Antibiotic administration and possible intubation are associated with epiglottitis.

Rationale 2: Sputum specimens will not assist in the diagnosis of LTB. Rationale 3: Throat cultures are not obtained for LTB, because it is viral, and swabbing the throat could cause complete obstruction to occur.

Rationale 4: Nebulized epinephrine and dexamethasone are given for LTB. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25-3 Question 3 Type: MCSA Which nursing diagnosis would be most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?

1. Activity intolerance 2. Tissue perfusion, ineffective (peripheral) 3. Pain, acute 4. Decreased cardiac output Correct Answer: 1 Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply and demand.

Rationale 2: Tissue perfusion (peripheral) is not affected by this respiratory disease process.

Rationale 3: Pain is not usually associated with acute bronchiolitis.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: Cardiac output is not compromised during an acute phase of bronchiolitis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25-5 Question 4 Type: MCSA 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. Begin administration of intravenous fluids.

2. Obtain a blood sample to send to the lab for electrolyte analysis.

3. Begin oxygen per nasal cannula at 1 liter.

4. Medicate for pain.

Correct Answer: 3 Rationale 1: Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed.

Rationale 2: Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed.

Rationale 3: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula at 1 liter should be started initially.

Rationale 4: Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25-3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 5 Type: MCSA A two-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?

1. Throat culture 2. Medical history 3. Vital signs 4. Assessment of breath sounds Correct Answer: 1 Rationale 1: Throat cultures 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.

Rationale 2: Medical history should be obtained, which assists in diagnosis.

Rationale 3: Vital signs should always be taken when assessment is done.

Rationale 4: Assessment of breath sounds is essential for diagnosis.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-6 Question 6 Type: MCSA The family rushes a four-month-old infant to the hospital after finding the infant not breathing. The child is diagnosed as a victim of sudden infant death syndrome. Supportive care for this family would include: 1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints.

2. Allowing parents to hold, touch, and rock the dead infant.

3. Advising parents that an autopsy is not necessary.

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4. Interviewing parents to determine the cause of the SIDS incident.

Correct Answer: 2 Rationale 1: Parents will want any personal items available.

Rationale 2: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say goodbye to their baby.

Rationale 3: The death of an infant without a known medical condition is an indication for an autopsy.

Rationale 4: The parents need to know that SIDS is not their fault.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-6 Question 7 Type: MCSA 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. Hepatitis B. 2. Polio.

3. Measles, mumps, and rubella (MMR).

4. Haemophilus influenzae type B (HIB).

Correct Answer: 4 Rationale 1: Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 2: Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 3: Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 4: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25-5 Question 8 Type: MCSA A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the clinic and report that the child's urine is orange. The nurse should advise the parents to: 1. Encourage the child to drink cranberry juice.

2. Expect orange-colored urine while the child is on rifampin.

3. Bring the child to the clinic for a urinalysis.

4. Bring the child to the clinic for a radiograph of the kidneys.

Correct Answer: 2 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.

Rationale 2: Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect.

Rationale 3: 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.

Rationale 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-6 Question 9 Type: MCSA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The nurse is evaluating the parent's understanding of teaching related to environmental control for their child's asthma management. Which statement by the parents indicates that they understand the teaching?

1. "We're glad the dog can continue to sleep in our child's room."

2. "We'll keep the plants in our child's room dusted."

3. "We'll be sure to use the fireplace often to keep the house warm in the winter."

4. "We will replace the carpet in our child's bedroom with tile."

Correct Answer: 4 Rationale 1: When possible, pets and plants should not be kept in the home.

Rationale 2: When possible, pets and plants should not be kept in the home.

Rationale 3: Smoke from fireplaces should be eliminated.

Rationale 4: Control of dust in the child's bedroom is an important aspect of environmental control for asthma management.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 25-7 Question 10 Type: MCSA A newborn who is 24 hours old 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. Rectal prolapse.

2. Constipation.

3. Steatorrheic stools.

4. Meconium ileus.

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Rectal prolapse is a complication of the large, bulky fatty stools.

Rationale 2: Constipation is not a symptom of cystic fibrosis.

Rationale 3: Steatorrhea and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child.

Rationale 4: Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-7 Question 11 Type: MCSA The nurse is teaching the parents of a patient who is newly diagnosed with cystic fibrosis how to administer the pancreatic enzymes. The nurse will advise the parents to administer the enzymes: 1. qid (four times daily).

2. bid (twice daily).

3. With meals and snacks.

4. Every six hours around the clock.

Correct Answer: 3 Rationale 1: A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 2: A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 3: Pancreatic enzymes are administered with meals and large snacks.

Rationale 4: A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-7 Question 12 Type: MCSA A mother of a three-year-old tells the nurse that her child often puts small toys in his mouth and she is concerned about choking. She asks the nurse what she should do if the child chokes. In addition to recommending the mother take a CPR course, the best response by the nurse would be to: 1. Show the mother how to do cardiac compressions and rescue breathing.

2. Recommend the mother perform back blows and chest thrusts.

3. Teach the mother how to perform abdominal thrusts.

4. Tell the mother to do nothing until the child loses consciousness.

Correct Answer: 3 Rationale 1: Cardiac compressions and rescue breathing is not the first thing that the mother needs to know.

Rationale 2: This is the treatment for a choking infant, not a child.

Rationale 3: Giving abdominal thrusts is the correct intervention for a choking child.

Rationale 4: The mother should respond to the choking child before the child loses consciousness.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-5 Question 13 Type: MCMA A premature infant develops acute respiratory distress syndrome (ARDS). How will the nurse position the baby?

Standard Text: Select all that apply.

1. Upright Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Semi-Fowler’s position 3. Prone position 4. With his head hyperextended 5. With his head in a sniffing position Correct Answer: 2,5 Rationale 1: An infant cannot be placed in an upright position.

Rationale 2: The semi-Fowler’s position elevates the head of bed. This allows better movement of the diaphragm.

Rationale 3: Prone positioning will not promote respirations.

Rationale 4: The head should not be hyperextended as that position does not open the airway in an infant.

Rationale 5: A sniffing position straightens and shortens the airway and is the position that is best.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-6 Question 14 Type: MCSA Two hours after admission for asthma exacerbation, the 10-year-old boy is lethargic with mottled skin color. He has increased the use of accessory muscles and demonstrates nasal flaring. He is unable to speak and his respiratory rate has increased. The nurse would suspect: 1. Improvement in his condition is imminent.

2. Respiratory failure is imminent.

3. The medical diagnosis is incorrect and the child should be diagnosed with pneumonia.

4. The child may be receiving too much oxygen, which is a respiratory depressant.

Correct Answer: 2 Rationale 1: His condition has worsened.

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Rationale 2: These are symptoms of impending failure. Intervention is necessary.

Rationale 3: Pneumonia is a complication of asthma exacerbation but that doesn’t indicate the medical diagnosis is incorrect.

Rationale 4: There is no indication the child is receiving too much oxygen.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-3 Question 15 Type: MCSA After a routine vaginal delivery, the infant transitions with the mother in the recovery room without difficulty.

Prior to being discharged from the recovery room, it is noted that the infant’s respiratory rate is 102 and the lungs are clear to auscultation. Based on these findings, an appropriate transfer for this infant would be to: 1. The newborn nursery for the first bath.

2. The NICU and placed under an over-bed warmer for observation.

3. To the mother’s room to promote bonding with the parents.

4. The newborn nursery for its first feeding.

Correct Answer: 2 Rationale 1: The infant is tachypneic. Bathing will only add to the respiratory distress and should be avoided.

Rationale 2: This infant needs to remain under constant observation due to the respiratory rate.

Rationale 3: The infant needs to be monitored.

Rationale 4: With a respiratory rate this high, aspiration is likely so feeding should be avoided.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 25-4 Question 16 Type: MCSA A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent lifethreatening event). The physician is to see the infant to write medical orders. The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently?

1. Place the child on an apnea monitor.

2. Place the child on nasal cannula oxygen.

3. Draw blood for arterial blood gases.

4. Place the child on contact isolation.

Correct Answer: 1 Rationale 1: This is appropriate monitoring of the infant.

Rationale 2: Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen.

Rationale 3: Lab tests are not an independent action.

Rationale 4: There is no indication of a respiratory infection. At this time, contact isolation is not indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-4 Question 17 Type: MCSA An infant was born at 34 weeks’ gestation and is being treated in the NICU for apnea of prematurity. The infant is in an isolette with an apnea monitor and intravenous fluids. The apnea monitor sounds, and the nurse checks the infant to find the infant is not breathing. The initial intervention by the nurse would be to: 1. Administer oxygen.

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2. Perform back blows and chest thrusts.

3. Call a code.

4. Stroke the infant’s back.

Correct Answer: 4 Rationale 1: If the infant is not breathing, oxygen will not help.

Rationale 2: This is intervention for choking, not apnea.

Rationale 3: A code is not the initial response. If the nurse is unable to restart breathing, then a code should be initiated.

Rationale 4: Tactile stimulation is often sufficient to restart the infant’s respirations. Apnea of prematurity is due to immaturity of the respiratory center.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-2 Question 18 Type: MCMA A child is being discharged from the hospital following treatment of asthma. Discharge medications include cromolyn sodium (a mast cell stabilizer). Nursing instructions to the parents about this medication would include explaining: Standard Text: Select all that apply.

1. The medication works to prevent exacerbations.

2. The medication should be administered at the first symptom of an asthmatic attack.

3. The medication should be taken on a daily basis.

4. Avoid taking the medication if the child has symptoms of a cold.

5. The medication desensitizes the child against specific allergens.

Correct Answer: 1,3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: This statement is true. Cromolyn Sodium is used to inhibit an asthmatic response to allergens.

Rationale 2: This is incorrect. This medication does not improve the child’s condition during an asthmatic attack.

Rationale 3: This is a preventative medication so doses should not be missed.

Rationale 4: The medication should be taken daily.

Rationale 5: This medication does not desensitize the child against allergens.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-7 Question 19 Type: MCSA The nurse stops at the scene of an accident and finds a child conscious but with a sucking wound of the chest. The immediate action by the nurse would be to: 1. Place the child in trendelenburg.

2. Begin rescue breathing.

3. Begin cardiac resuscitation.

4. Cover the wound with an air occlusive dressing.

Correct Answer: 4 Rationale 1: This would not be the appropriate response to a sucking chest wound.

Rationale 2: The child is conscious. Rescue breathing is not appropriate at this time.

Rationale 3: There is no need for cardiac resuscitation at this time.

Rationale 4: This prevents more air from entering the chest and is appropriate.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-8

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Ball, Child Health Nursing, 3/E Chapter 26 Question 1 Type: MCSA 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. Is warm, with a capillary refill of less than three seconds.

3. Has decreased sensation with a weakened dorsalis pedis pulse.

4. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.

Correct Answer: 2 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.

Rationale 2: 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.

Rationale 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-3 Question 2 Type: MCSA The nurse has admitted a child with a cyanotic heart defect. Which initial lab result will the nurse anticipate?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. A low platelet count 2. A high white blood cell count 3. A high hemoglobin 4. A low hematocrit Correct Answer: 3 Rationale 1: The platelets would be normal.

Rationale 2: The white blood cell count would not be high unless an infection was present.

Rationale 3: The child's bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects.

Rationale 4: The hematocrit would not be low.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-3 Question 3 Type: MCSA The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

1. Hypothermia related to decreased metabolic state 2. Acute pain related to the effects of a congenital heart defect 3. Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect 4. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow Correct Answer: 4 Rationale 1: Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Rationale 2: Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

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Rationale 3: VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis.

Rationale 4: Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26-3 Question 4 Type: MCSA 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. Transposition of the great vessels 2. Patent ductus arteriosus 3. Coarctation of the aorta 4. Atrial septal defect Correct Answer: 3 Rationale 1: These defects are not associated with blood pressures that are different in upper and lower extremities.

Rationale 2: These defects are not associated with blood pressures that are different in upper and lower extremities.

Rationale 3: 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 because of obstruction of circulation to the lower extremities.

Rationale 4: These defects are not associated with blood pressures that are different in upper and lower extremities.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-3 Question 5 Type: MCMA An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions should the nurse implement?

Standard Text: Select all that apply.

1. Administer oxygen.

2. Place the child in knee-chest position.

3. Administer morphine and propranolol intravenously as ordered.

4. Draw blood for a serum hemoglobin.

5. Administer Benadryl as ordered.

Correct Answer: 1,2,3 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 kneechest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).

Rationale 2: 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 kneechest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).

Rationale 3: 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 kneechest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).

Rationale 4: The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed.

Rationale 5: Benadryl is not appropriate for this child.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-3 Question 6 Type: MCSA An infant has been diagnosed with a mild 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 heart defect should: 1. Have a low-grade fever until the defect is repaired.

2. Maintain normal activity.

3. Not develop congestive heart failure.

4. Not be given antipyretics.

Correct Answer: 2 Rationale 1: 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.

Rationale 2: A child with a mild cyanotic heart defect should be treated as normally as possible without activity adjustment.

Rationale 3: Any child with a heart defect could develop congestive heart failure.

Rationale 4: Fevers are treated with antipyretics so that dehydration is avoided.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-4 Question 7 Type: MCSA A two-month-old infant with a congenital heart defect has been admitted to the pediatric intensive care unit with congestive heart failure. Nursing care for this child should include which intervention?

1. Monitor respirations during active periods.

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2. Give larger feedings less often to conserve energy.

3. Organize activities to allow for uninterrupted sleep.

4. Force fluids appropriate for age.

Correct Answer: 3 Rationale 1: Respirations are difficult to monitor during active periods, making this an unrealistic goal.

Rationale 2: Feedings should be small-volume, high-calorie.

Rationale 3: It is important to allow for uninterrupted sleep to decrease metabolic demands on the heart.

Rationale 4: Fluids should be restricted to high-calorie and low-volume in order to avoid overloading the lungs with fluid.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-6 Question 8 Type: MCSA A toddler has been started on digoxin (Lanoxin) for cardiac failure. The nurse will teach the parents to monitor the child for signs of digoxin (Lanoxin) toxicity including: 1. Bradycardia.

2. Tinnitus.

3. Ataxia.

4. Lowered blood pressure.

Correct Answer: 1 Rationale 1: Early signs of digoxin (Lanoxin) toxicity are bradycardia and arrhythmias Rationale 2: Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

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Rationale 3: Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Rationale 4: Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-4 Question 9 Type: MCSA 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 not receive routine immunizations.

2. Should be restricted from most play activities.

3. Can be expected to have a fever for several weeks following the surgery.

4. Should receive prophylactic antibiotics for any dental, oral, or upper respiratory tract procedures.

Correct Answer: 4 Rationale 1: Immunizations should be provided according to the schedule.

Rationale 2: The child should live a normal and active life following repair of a cardiac defect.

Rationale 3: Fever is not expected for a prolonged period after surgery, and any unexplained fever should be reported.

Rationale 4: Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 10 Type: MCSA A child has had a heart transplant. In preparation for discharge, the nurse provides teaching about home medications. The nurse recognizes that postoperative teaching has been successful when the parents state that the child is on cyclosporin A to: 1. Treat hypertension.

2. Reduce serum cholesterol level.

3. Prevent rejection.

4. Treat infections.

Correct Answer: 3 Rationale 1: Calcium channel blockers may be used to treat hypertension.

Rationale 2: Lovastatin is given to reduce serum cholesterol level.

Rationale 3: Cyclosporin A is given to prevent rejection.

Rationale 4: An antibiotic may be given to treat an infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26-5 Question 11 Type: MCSA A child has been admitted to the hospital unit in congestive heart failure (CHF). Symptoms related to this admission diagnosis would include: 1. Tachycardia.

2. Weight loss.

3. Increased blood pressure.

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4. Bradycardia.

Correct Answer: 1 Rationale 1: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster.

Rationale 2: The weight, instead of decreasing, increases, because of retention of fluids.

Rationale 3: Blood pressure does not increase in CHF. Rationale 4: Bradycardia is a serious sign and can indicate impending cardiac arrest.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-6 Question 12 Type: MCSA A child diagnosed with congestive heart failure is started on digoxin (Lanoxin) and spironolactone (Aldactone).

The mother questions why the child was placed on spironolactone (Aldactone) instead of furosemide (Lasix), which her elderly grandmother uses. The nurse explains that spironolactone (Aldactone) is a diuretic that: 1. Produces rapid diuresis.

2. Blocks reabsorption of sodium and water in renal tubules.

3. Spares potassium.

4. Promotes vascular relaxation.

Correct Answer: 3 Rationale 1: Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules.

Rationale 2: Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules.

Rationale 3: Spironolactone (Aldactone) is a maintenance diuretic that is potassium-sparing. Hypokalemia would increase the risk of lanoxin toxicity.

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Rationale 4: ACE inhibitors promote vascular relaxation.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-6 Question 13 Type: MCSA A diagnosis of rheumatic fever is being ruled out for a child. The parents cannot remember the child having a recent streptococcal infection. Which lab test would confirm a recent streptococcal infection?

1. Erythrocyte sedimentation rate 2. Throat culture 3. C-reactive protein 4. Antistreptolysin-O (ASO) titer Correct Answer: 4 Rationale 1: An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation.

Rationale 2: A culture can indicate a current streptococcal infection.

Rationale 3: An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation.

Rationale 4: The lab test for antistreptococcal antibodies is an antistreptolysin-O (ASO) titer.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-7 Question 14 Type: MCSA Which athletic activity could the nurse recommend for a school-age child with pulmonary-artery hypertension?

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1. Golf 2. Basketball 3. Cross-country running 4. Soccer Correct Answer: 1 Rationale 1: A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea, such as golf.

Rationale 2: Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

Rationale 3: Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

Rationale 4: Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-7 Question 15 Type: MCMA A 10–month-old infant is seen in the emergency department for a heart rate of 226 beats per minute.

Supraventricular tachycardia is diagnosed. The emergency department nurse will prepare to assist with which possible treatments?

Standard Text: Select all that apply.

1. Administration of intravenous adenosine (Adenocard) 2. Administration of intravenous amiodarone (Cardarone) 3. Preparation for cardioversion 4. Application of ice to the face 5. Having the child perform a Valsalva maneuver Correct Answer: 1,2,3,4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation.

Rationale 2: Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation.

Rationale 3: Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation.

Rationale 4: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate including the application of ice or iced saline solution to the face to reduce the heart rate.

Rationale 5: A 10-month-old child cannot be instructed to hold her breath and bear down as with a bowel movement.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-7 Question 16 Type: MCMA Following an automobile accident, an eight-year-old child is admitted to the emergency department with injuries that lead to hemorrhaging. The nurse would recognize the early signs of hypovolemic shock would include: Standard Text: Select all that apply.

1. Increased work of breathing.

2. Pulse rate of 56.

3. Heart rate 130.

4. Capillary refill time greater than three seconds.

5. Blood pressure 72/42.

Correct Answer: 1,3,4 Rationale 1: Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume.

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Rationale 2: Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate.

Rationale 3: Tachycardia is an early compensatory mechanism for hypovolemia in a child.

Rationale 4: Decreased capillary refill time would be an early indicator of decreased fluid volume and compensation.

Rationale 5: Decreased blood pressure is a later finding and would not occur until other compensatory mechanisms were exhausted.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-8 Question 17 Type: MCSA Following an injury that led to hypovolemic shock, a child is being treated in the emergency department. Which treatment measures would be given the highest priority for this child with hypovolemic shock?

1. Assess the cause of bleeding.

2. Establish an open airway and administer oxygen.

3. Administer analgesics for control of pain.

4. Provide replacement of volume.

Correct Answer: 2 Rationale 1: Airway patency and replacement of volume are priorities before assessing the cause of the bleeding.

Rationale 2: Airway patency and oxygen delivery (breathing) are always first in the treatment for a client with health concerns.

Rationale 3: Pain would be a consideration but would not be attended to as a first priority.

Rationale 4: Replacement of volume is vital but would follow establishing airway and breathing.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-8 Question 18 Type: SEQ The nurse is explaining fetal circulation to a woman pregnant with a fetus with a congenital heart defect. The nurse explains that there are three fetal structures and explains that blood flow from the umbilical vein flows through the three fetal structures in the following order: Standard Text: Click and drag the options below to move them up or down.

Choice 1. Ductus arteriosus Choice 2. Ductus venosus Choice 3. Foramen ovale Correct Answer: 2,3,1 Rationale 1: The ductus arteriosus connects the pulmonary artery to the aorta and is the last structure that blood reaches.

Rationale 2: The ductus venosus connects the umbilical vein to the inferior vena cava bypassing the liver. It is the first structure that blood reaches.

Rationale 3: The foramen ovale connects the right atrium to the left ventricle and bypasses the lungs. It is the second structure that blood reaches.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-1 Question 19 Type: MCSA A term infant is found to have a congenital heart defect. During a cardiac catheterization, a stent is inserted to maintain the ductus arteriosus. The parents ask the nurse to explain the purpose of this procedure. The nurse’s response would include the information that the stent: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed.

2. Is used to close the ductus arteriosus to prevent mixing of arterial and venous blood.

3. Will redirect the blood so that blood bypasses the right ventricle.

4. Connects the ventricle to the atrium.

Correct Answer: 1 Rationale 1: This statement is accurate.

Rationale 2: A stent maintains an opening; it does not close an opening.

Rationale 3: A stent maintains the ductus as patent. It does not bypass the ventricle.

Rationale 4: This is not the purpose of the stent.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-3 Question 20 Type: MCMA An infant with a congenital heart defect is being discharged home until the infant reaches an appropriate weight for the corrective surgery. The nurse would teach the parents infant feeding techniques including: Standard Text: Select all that apply.

1. Breastfeed if possible.

2. Complete each feeding within 30 minutes.

3. Position the infant flat to promote swallowing.

4. Dilute the formula with extra water to ensure adequate fluid intake.

5. Burp the infant frequently.

Correct Answer: 1,2,5

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Rationale 1: Breastfeeding is recommended because it provides antibodies to help protect the infant from infection.

Rationale 2: Allowing the infant to nurse for more than 30 minutes will burn more calories than calories are gained.

Rationale 3: The infant should be positioned at a 45 degree angle to reduce the workload of the heart.

Rationale 4: The formula should not be diluted beyond the label recommendations as it would lower the caloric count.

Rationale 5: This is appropriate for the infant with a congenital heart defect as well as the normal infant.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-4 Question 21 Type: MCSA A four-year-old child is being emotionally prepared for open heart surgery. The nurse will want to provide the child with which information?

1. Who will be performing the surgery 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine 4. What the ICU will look and sound like when the child wakes up Correct Answer: 4 Rationale 1: The parents know the name of the surgeon. It will mean nothing to a four-year-old child.

Rationale 2: The child will be asleep during surgery and therefore does not need to know about the procedure.

Rationale 3: This is beyond the understanding of a four-year-old.

Rationale 4: The child should be prepared in terms of what she will see, hear, smell, or feel.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-5 Question 22 Type: MCSA A child is admitted to the hospital unit with a diagnosis of Kawasaki disease. The physician writes the following orders. Which order would the nurse question?

1. Contact isolation 2. Oral aspirin (dose appropriate for weight) every eight hours 3. Echocardiogram 4. Vital signs every four hours Correct Answer: 1 Rationale 1: The child is not contagious so contact isolation is not appropriate.

Rationale 2: Aspirin is used as an anti-inflammatory and is prescribed around the clock. This is appropriate.

Rationale 3: This exam will be used as a baseline to compare against as the child recovers, to assist in monitoring for cardiac lesions.

Rationale 4: The child will need close monitoring during the early period of the disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-7 Question 23 Type: MCSA A seven-year-old girl has been diagnosed with rheumatic fever. The physician has talked with the parents and child and explained the disease and the planned medical treatment. Which statement by the parents needs further clarification?

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. “I understand rheumatic fever is a strep infection of the heart.”

2. “My child will be on bed rest for several weeks.”

3. “My child will be treated with aspirin and/or corticosteroids.”

4. “Once my child has recovered, she will still need to be monitored for sequelae to the disease.”

Correct Answer: 1 Rationale 1: Rheumatic fever is not a strep infection of the heart but an autoimmune connective tissue disease in response to a previous strep infection. This statement requires clarification.

Rationale 2: This statement is correct. No further clarification is needed.

Rationale 3: This statement is correct and needs no clarification.

Rationale 4: Children who have had one episode of rheumatic fever are at greater risk for future episodes. In addition, long term valve damage may occur. This statement needs no further clarification.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26-7 Question 24 Type: MCSA The nurse is off-duty and watching a youth baseball game when one of the players gets hit in the chest with a ball.

The child immediately drops to the ground and is unresponsive. What is the priority action for the nurse to initiate?

1. Initiate CPR. 2. Call 911.

3. Find the parents and offer them comfort.

4. Check the child for hemorrhage.

Correct Answer: 1

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Rationale 1: This situation is an example of cardiac concussion. Survival chances improve if CPR is initiated immediately.

Rationale 2: Other people can call 911. Cardiac resuscitation must be initiated immediately.

Rationale 3: This is an appropriate action but not a priority.

Rationale 4: This type of injury often has no external symptoms of injury.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-7

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Ball, Child Health Nursing, 3/E Chapter 27 Question 1 Type: MCSA 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 in younger children 2. High levels of IgA in the newborn 3. Absent lymphoid tissue in the young child 4. Underdeveloped thymus glands in the infant Correct 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.

Rationale 2: IgA is not present at birth. Development of IgA begins at two weeks of age but doesn’t reach adult levels until the age of six.

Rationale 3: Lymphoid tissue, such as the spleen and tonsils, is present at birth.

Rationale 4: The thymus is large at birth and grows during childhood, decreasing by adulthood.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-2 Question 2 Type: MCSA A premature infant is at greater risk for infection than a full-term infant because of a reduced number of which immunoglobulin?

1. IgE

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2. IgG 3. IgA 4. IgM Correct Answer: 2 Rationale 1: IgE does not cross the placenta and is not present at birth in either preterm or full-term infants.

Rationale 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.

Rationale 3: IgA does not cross the placenta and is not present at birth in either preterm or full-term infants.

Rationale 4: IgM does not cross the placenta. The levels are low at birth in both preterm and full-term infants.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-1 Question 3 Type: MCSA The nurse is planning care for a child with acquired immune deficiency syndrome (AIDS). Which vaccines should be avoided in the child with AIDS? 1. Inactivated polio vaccine (a killed virus vaccine) 2. Tetanus toxoid vaccination 3. Varicella vaccine (an attenuated virus vaccine) 4. Acellular pertussis vaccine Correct Answer: 3 Rationale 1: Killed virus vaccines are safe to administer to the child with AIDS as there is no risk of acquiring an infection.

Rationale 2: A toxoid vaccination is made of a toxin that has been produced by the organism but does not include living organisms.

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Rationale 3: A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease.

Rationale 4: Acellular pertussis vaccine contains a protein from pertussis rather than the whole cell.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-2 Question 4 Type: MCSA The nurse is planning to discharge a child newly diagnosed with HIV infection. Which discharge instruction should be included for this child and her family?

1. Eat raw fruits.

2. Avoid playing sports.

3. Restrict school attendance.

4. Cover open wounds.

Correct Answer: 4 Rationale 1: The child should avoid eating raw fruits and vegetables unless they are peeled, to decrease ingestion of microorganisms.

Rationale 2: The child with HIV should participate in sports. While injuries are possible, it is unlikely that large quantities of blood will be present.

Rationale 3: The majority of children with HIV can attend school without restrictions.

Rationale 4: Wounds should be covered, and gloves should be worn when treating a child's cuts and scrapes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27-3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 5 Type: MCSA An adolescent has systemic lupus erythematosus (SLE). Which action by the teen indicates acceptance of the body changes that occur because of SLE? 1. Attends school but doesn’t stay for after-school activities 2. Discusses the body changes with health care personnel only 3. Discusses the body changes with her best friend 4. Only attends small parties at friends’ homes Correct Answer: 3 Rationale 1: Avoiding social activities does not show acceptance of body changes.

Rationale 2: Discussing changes only with health care personnel does not indicate the teen has adjusted to the body image changes.

Rationale 3: Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image.

Rationale 4: Avoiding social activities other than those involving immediate friends indicates the teen is still concerned with body image.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27-7 Question 6 Type: MCSA An 11-year-old boy with rheumatoid arthritis wants to participate in the school sports programs. The boy asks the nurse to recommend a sporting activity for him. Which activity would be the most appropriate for the nurse to recommend?

1. Baseball 2. Basketball Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Football 4. Swimming Correct Answer: 4 Rationale 1: Baseball places stress on the knee joints.

Rationale 2: Basketball involves running, which will stress the joints.

Rationale 3: All positions in football will cause stress to the joints.

Rationale 4: Swimming helps to exercise all the extremities without putting undue stress on joints.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-7 Question 7 Type: MCSA The nurse is caring for a child with rheumatoid arthritis. Which is an appropriate nonpharmacologic measure to reduce the joint pain associated this disease?

1. Elevation of the extremity 2. Immobilization 3. Massage 4. Application of moist heat Correct Answer: 4 Rationale 1: Elevation of the extremity would not have an effect on reducing pain in rheumatoid arthritis.

Rationale 2: Immobilization can lead to contractures. Range-of-motion to the involved joint should be maintained.

Rationale 3: Massage of extremities should be avoided because of potential risk for emboli.

Rationale 4: Moist heat can promote relief of pain and decrease joint stiffness.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-7 Question 8 Type: MCSA The nurse is caring for a child who experiences an anaphylactic shock reaction. In which position will the nurse place the child?

1. In Trendelenburg position 2. Flat, with legs slightly elevated 3. In high Fowler's position 4. In reverse Trendelenburg position Correct Answer: 2 Rationale 1: The Trendelenburg position has the head of the bed lowered and 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.

Rationale 2: 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.

Rationale 3: 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.

Rationale 4: 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.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-9 Question 9 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

A child has been placed on an oral corticosteroid for a rash caused by graft-versus-host disease. The nurse will monitor the child for the common side effects of corticosteroids including: 1. Hyperglycemia.

2. Hepatic toxicity.

3. Seizures.

4. Renal toxicity.

Correct Answer: 1 Rationale 1: Hyperglycemia is a side effect of steroid therapy.

Rationale 2: Hepatic toxicity is not a side effect associated with steroid therapy.

Rationale 3: Seizures are not a side effect associated with steroid therapy.

Rationale 4: Renal toxicity is not a side effect associated with steroid therapy.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-9 Question 10 Type: MCSA A nurse has begun an infusion of intravenous immunogloblin (IVIG) to a child who has combined immunodeficiency disease. In which situation should this infusion be stopped?

1. The child complains of discomfort at the IV site.

2. The child develops severe shaking, chills, and fever.

3. The child complains of thirst.

4. The child experiences a mild headache.

Correct Answer: 2 Rationale 1: The site should be checked for phlebitis, but this would not be an indication of a reaction to IVIG. Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: 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.

Rationale 3: Thirst is not an indication of a reaction.

Rationale 4: A mild headache is an adverse side effect of IVIG but not a severe reaction.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-6 Question 11 Type: MCMA After a severe allergic reaction, an EpiPen is prescribed for the 10-year-old child. Instructions to be given to the child and the family would include: Standard Text: Select all that apply.

1. The child should always have the EpiPen readily available.

2. The parents should learn to administer the EpiPen as the child is too young to self-administer.

3. Once an EpiPen has been administered, there is no need for additional follow-up.

4. The EpiPen has an expiration date that should be checked regularly, and the pen should be replaced as needed.

5. The child should wear a MedicAlert bracelet.

Correct Answer: 1,4,5 Rationale 1: This is appropriate care.

Rationale 2: Both the child and family members should be taught administration of the EpiPen. Rationale 3: The EpiPen effect is good for approximately 20 minutes. The child should be transported to the hospital immediately after administering the EpiPen. Rationale 4: An expired EpiPen may have less than desired effects.

Rationale 5: If the child is unable to speak due to anaphylaxis, it is important that rescuers have information about the child’s allergies.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-9 Question 12 Type: MCSA A teenage girl has recently been diagnosed with systemic lupus erythematosus (SLE). In teaching the girl about her disease, the nurse explains that the teenager needs to avoid which typical teenage activity?

1. Receiving a manicure and a pedicure 2. Daily hair shampoos 3. Using a tanning bed 4. Attending late night parties and dances Correct Answer: 3 Rationale 1: Manicures and pedicures do not place the child at any risk.

Rationale 2: Although one symptom of SLE can be alopecia, gentle shampooing is not a cause of this symptom.

Rationale 3: Individuals with SLE have photosensitivity, and tanning beds can lead to exacerbations as well as skin damage from sun burns.

Rationale 4: Although adequate rest is important for the teenager with SLE, the teenager can “catch up” on her sleep the next day.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-7 Question 13 Type: MCSA

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The nurse is preparing the hospital room for admission of a child with multiple allergies including cow’s milk, peanuts, and latex. The nurse’s priority responsibility in preparing for this child would include: 1. Evaluating the hospital room for equipment containing latex.

2. Ordering an EpiPen for the child.

3. Notifying dietary of the milk and peanut allergy.

4. Placing a sign on the door which identifies all allergies.

Correct Answer: 1 Rationale 1: This is appropriate as latex allergies can be life threatening. Many pieces of medical equipment may contain latex.

Rationale 2: Nurses do not prescribe or dispense medication, so this is inappropriate.

Rationale 3: This action should be taken but is not the priority.

Rationale 4: Depending on hospital policy, there may be some sign to indicate allergies, but this is not the priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-8 Question 14 Type: MCSA The child is recovering from a bone marrow transplant. Which is the priority nursing concern in this early stage management?

1. Early recognition of symptoms of graft-versus-host disease.

2. Providing discharge instructions to the parents.

3. Avoiding latex products.

4. Monitoring the child for return of bone marrow function.

Correct Answer: 1 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: The nurse should be assessing for symptoms of graft-versus-host disease so that medical treatment can begin.

Rationale 2: Although discharge planning begins at admission, it is too early to provide discharge instructions.

Rationale 3: There is no indication in the stem that the child has a latex allergy.

Rationale 4: The priority for this child is to monitor for graft-versus-host disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27-6 Question 15 Type: MCMA A child has an anaphylactic reaction to contrast dye used in an X-ray. After the emergency is over and the child is stable in the intensive care unit, the nurse explains to the parents what happens in anaphylaxis. The nurse explains that histamine is released during an anaphylactic reaction and that the action of histamine includes: Standard Text: Select all that apply.

1. Release of IgE antibodies.

2. Smooth muscle contraction.

3. Increased capillary permeability.

4. Vasoconstriction.

5. Red cell destructions Correct Answer: 2,3 Rationale 1: IgE antibodies cause the release of histamine, not the other way around.

Rationale 2: Smooth muscle contraction causes the constriction of the bronchioles, which causes the wheezing and respiratory distress.

Rationale 3: Increased capillary permeability causes the plasma to leak into surrounding tissues, including the lungs, leading to pulmonary edema.

Rationale 4: Anaphylaxis causes vasodilation, not vasoconstriction.

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Rationale 5: Histamine does not cause red cell destruction.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-9 Question 16 Type: MCSA The nurse is discussing the immune protection of the newborn with a pregnant woman. The nurse tells the mother that her body will provide her baby with what type of antibodies?

1. IgM 2. IgA 3. IgD 4. IgG Correct Answer: 4 Rationale 1: IgM is the first antibody produced with primary immune response. It does not cross the placenta.

Rationale 2: IgA does not cross the placenta.

Rationale 3: Although the function of IgD is not fully understood, it is not thought to cross the placenta.

Rationale 4: IgG crosses the placenta and provides the newborn with passive immunity.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-1 Question 17 Type: MCSA

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A two-month-old infant has been diagnosed with severe combined immunodeficiency disease (SCID). The physician talked with the parents about the planned treatment and prognosis for the infant. Which statement by the parents indicates the need for additional education?

1. “My child will receive intravenous immune globulins as a way to help him fight infection.”

2. “Within days of receiving a stem cell transplant, my child will be cured.”

3. “If my child needs a blood transfusion, it should be with irradiated blood cells.”

4. “Antibiotics will be used as necessary to help my child fight infections.”

Correct Answer: 2 Rationale 1: This statement is correct and needs no additional teaching.

Rationale 2: It takes three to four months for the transplant to begin to work. The nurse needs to clarify this information.

Rationale 3: This information is correct, as irradiated blood cells help prevent graft-versus-host disease in the event a transfusion is needed.

Rationale 4: This statement is correct and requires no additional teaching.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27-5

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Ball, Child Health Nursing, 3/E Chapter 28 Question 1 Type: MCSA Immediately after delivery, the nurse prepares to give the newborn a vitamin K injection. The new father is watching and asks the nurse why the baby is receiving a “shot.” The nurse would explain that vitamin K injections are given to newborn infants to: 1. Activate clotting factors.

2. Break up blood clots.

3. Promote red blood cell function and assist in gas exchange.

4. Promote the production of hemoglobin.

Correct Answer: 1 Rationale 1: Levels of clotting factors are lower in infants, so vitamin K is given prophylactically to activate essential clotting factors.

Rationale 2: Vitamin K is given to promote clotting.

Rationale 3: Clotting factors do not carry oxygen or carbon dioxide.

Rationale 4: Vitamin K has no effect on the production of hemoglobin.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-4 Question 2 Type: MCSA Which of the following parental demonstrations indicates that the parents 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.

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2. The child's vitamin C consumption is limited after one year of age.

3. The parents start iron-fortified infant cereal at four to six months of age.

4. Cow's milk is introduced into the child's diet at six months of age.

Correct Answer: 3 Rationale 1: The infant's maternal iron stores are depleted by six months. Infants who are not breastfed should get iron-fortified formula.

Rationale 2: Vitamin C should be started at six to nine months of age and continued because foods rich in vitamin C improve iron absorption.

Rationale 3: Starting iron-fortified infant cereal at four to six months of age is recommended for prevention of iron deficiency in children.

Rationale 4: Cow's milk should not be introduced until 12 months of age.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28-2 Question 3 Type: MCSA A child has been diagnosed with sickle-cell disease. Both parents deny having the disease themselves. The parents ask the nurse how their child got this disease. The nurse recognizes that the only possible explanation of the etiology is: 1. The father is not the biological father of the infant.

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 and the father of the child have the sickle-cell trait.

Correct Answer: 4 Rationale 1: There is no indication that the father is not the actual parent. Both parents could be carriers of the disorder but unaware of their status.

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Rationale 2: Both parents must have the trait for the child to have a 25% chance of having this disease.

Rationale 3: Both parents must have the trait for the child to have a 25% chance of having this disease.

Rationale 4: Sickle-cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have a 25% chance of having this disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-2 Question 4 Type: MCMA The nurse is teaching parents of the child with sickle-cell disease how to avoid precipitating factors that can contribute to a sickle-cell crisis. Which are precipitating factors that could contribute to a sickle-cell crisis?

Standard Text: Select all that apply.

1. Regular exercise 2. Fever 3. Dehydration 4. Altitude 5. Increased fluid intake Correct Answer: 2,3,4 Rationale 1: 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.

Rationale 2: Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis.

Rationale 3: Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis.

Rationale 4: Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis.

Rationale 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.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 5 Type: MCSA 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. At the end of the administration of the transfusion.

3. Within the first 20 minutes of administration of the transfusion.

4. Never; children with SCD do not have reactions.

Correct Answer: 3 Rationale 1: Transfusion reaction does not occur this long after the transfusion.

Rationale 2: Reactions generally occur at the onset or during the first 20 minutes of transfusion.

Rationale 3: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child during the first 20 minutes of the transfusion.

Rationale 4: Anyone can have a transfusion reaction during any transfusion.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-2 Question 6 Type: MCSA

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A child who has Beta-thalassemia is receiving numerous blood transfusions. The child is also receiving deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which is an action of deferoxamine that the nurse should convey?

1. Stimulates red blood cell production 2. Prevents iron overload 3. Provides vitamin supplementation 4. Prevents blood transfusion reactions Correct Answer: 2 Rationale 1: Desferal does not stimulate red blood cell production.

Rationale 2: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an ironchelating 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.

Rationale 3: Desferal does not provide vitamin supplementation.

Rationale 4: Desferal does not prevent blood transfusion reactions.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 7 Type: MCSA A child is admitted to the hospital and diagnosed with aplastic anemia. The parents ask the nurse what aplastic anemia is. Which would be the best description of aplastic anemia?

1. Causes a proliferation of white blood cells 2. Is characterized by abnormally shaped red 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 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: All blood cells are affected.

Rationale 2: Cells are normally shaped, just in insufficient numbers.

Rationale 3: In aplastic anemia, the bone marrow does not produce sufficient numbers of circulating blood cells.

Rationale 4: There is no known association with viral illness.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 8 Type: MCSA When caring for a child diagnosed with aplastic anemia, the nurse would educate the parents regarding which common symptoms?

1. Fatigue and fever 2. Runny nose and cough 3. Nausea and vomiting 4. Cyanosis and bradycardia Correct Answer: 1 Rationale 1: Fatigue secondary to anemia and fever related to infection secondary to neutropenia are common symptoms.

Rationale 2: Aplastic anemia is not associated with upper respiratory infections.

Rationale 3: Nausea and vomiting are not symptoms of aplastic anemia.

Rationale 4: The child would exhibit tachycardia rather than bradycardia, and there is no reason for cyanosis.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-6 Question 9 Type: MCSA 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 injury?

1. Occipital hematoma 2. Radial fracture 3. Dislocated shoulder 4. Abdominal abrasions Correct Answer: 1 Rationale 1: A potential intracranial bleed would receive highest priority because of the danger of increased intracranial pressure and potential neurologic damage.

Rationale 2: Although at risk for bleeding, this would not take priority over a head injury.

Rationale 3: A dislocation is not at high risk for bleeding or tissue ischemia.

Rationale 4: Although at risk for bleeding, this would not take priority over a head injury.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-6 Question 10 Type: MCSA 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 pressure to the area for at least 15 minutes.

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2. Apply a warm, moist pack to the area.

3. Perform some passive range-of-motion to the affected leg.

4. Keep the affected extremity in a dependent position.

Correct Answer: 1 Rationale 1: 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.

Rationale 2: Heat would increase the bleeding by dilating the superficial blood vessels.

Rationale 3: The extremity should be immobilized to prevent further bleeding; passive range-of-motion could cause further bleeding at the site.

Rationale 4: The extremity should be elevated, if possible, to prevent swelling at the site.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 11 Type: MCSA A child with hemophilia plans on participating in a bicycling club. Which recommendation should the nurse give to the child?

1. Wear kneepads, elbow pads, and a helmet while bicycling.

2. Consider a swim club instead of the bicycling club.

3. Do not join the club.

4. Participate only in the social activities of the club.

Correct Answer: 1 Rationale 1: 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.

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Rationale 2: Biking is an acceptable sport as long as protective equipment is worn, and the child should be encouraged to make choices when possible.

Rationale 3: Discouraging a child from joining a club would not foster growth and development.

Rationale 4: Participating only in the social aspects of the club would not encourage physical activity.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 12 Type: MCSA The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which would be a priority nursing intervention for this child?

1. Preparation for radiograph procedures 2. Monitoring of fluid restriction 3. Frequent ambulation 4. Monitoring of oxygen saturation and vital signs Correct Answer: 4 Rationale 1: DIC is not diagnosed with radiograph examination but by serum lab studies.

Rationale 2: Fluids need to be monitored but will not be restricted.

Rationale 3: Ambulation places stress on joints and can promote bleeding. The child with DIC should be placed on bed rest.

Rationale 4: In a child who has a bleeding and clotting disorder, the priority nursing intervention would be monitoring for life-threatening complications.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 13 Type: MCSA Which of the following is a priority nursing diagnosis for the child with idiopathic thrombocytopenic purpura (ITP)?

1. Ineffective breathing pattern 2. Nausea 3. Fluid-volume deficit 4. Risk for injury Correct Answer: 4 Rationale 1: Although in an advanced state TP can impact breathing, it does not usually cause ineffective breathing patterns.

Rationale 2: Nausea is not a symptom of ITP. Rationale 3: Fluid-volume deficits are not likely to occur with ITP. Rationale 4: ITP is the most common bleeding disorder in children, so risk for injury and subsequent bleeding is the priority nursing diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 28-4 Question 14 Type: MCSA A child with meningococcemia is being admitted to the pediatric intensive care unit. This child should be placed in which type of room?

1. Private room, in respiratory isolation 2. Private room, in protective isolation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Private room, but not in isolation 4. Semiprivate room Correct Answer: 1 Rationale 1: 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.

Rationale 2: The child does not need to be protected from others and does not need protective isolation.

Rationale 3: A patient with meningococcemia is contagious and must be placed in isolation.

Rationale 4: Meningococcemia is very contagious, and other children should not be exposed to a child who has been diagnosed with it.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28-6 Question 15 Type: MCSA 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. Rapid weaning of pain medications 2. Promotion of a diet high in protein 3. Encouraging adequate hydration 4. Restriction of activities Correct Answer: 3 Rationale 1: Rapid weaning is not necessary; reduction of pain medication should proceed at a rate dictated by the child's pain.

Rationale 2: A high-protein diet is not necessary; a well-balanced diet should be promoted.

Rationale 3: Adequate hydration will help prevent further sequestration and crisis.

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Rationale 4: Normal activities are not restricted.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 16 Type: MCSA For which complication(s) should the nurse observe during administration of Factor VIII to a child with hemophilia?

1. Fever and chills 2. Fat emboli 3. Nausea and vomiting 4. Congestive heart failure Correct Answer: 1 Rationale 1: 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.

Rationale 2: Although the nurse can watch for the symptoms of emboli, the nurse cannot directly observe for fat emboli formation.

Rationale 3: Nausea and vomiting are not usually associated with a transfusion reaction.

Rationale 4: Factor VIII is not a large volume, and the child is not at risk for CHF. Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-5 Question 17 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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 teaches the family the importance of avoiding which condition?

1. Respiratory infection and dehydration 2. Midrange altitudes 3. Weight loss without dehydration 4. Overhydration Correct Answer: 1 Rationale 1: The child with sickle-cell disease is at risk for infection, and dehydration can precipitate crisis.

Rationale 2: High altitudes with lower oxygen concentrations pose a risk; mid-altitude is not a risk factor.

Rationale 3: Weight loss is acceptable as long as hydration is maintained.

Rationale 4: Hydration should be encouraged; risk of overhydration is minimal.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 18 Type: MCMA Which of the following are major risks during the post-transplant phase of hematopoietic stem cell transplantation (HSCT)?

Standard Text: Select all that apply.

1. Bleeding 2. Thrombosis 3. Pancytopenia 4. Infection 5. Fluid volume overload Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1,3,4 Rationale 1: Suppression of platelets increases the risk for bleeding.

Rationale 2: There is no increased risk for thrombosis.

Rationale 3: It takes two to four weeks for the bone marrow to begin producing cells; the patient will show evidence of suppression until that time.

Rationale 4: Suppression of white blood cells increases the patient's risk for infection.

Rationale 5: There is no increased risk of excess fluid; the patient is at greater risk for dehydration.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-6 Question 19 Type: MCMA A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which concepts are important for the nurse to include in discharge education?

Standard Text: Select all that apply.

1. Keeping the child on a high-calcium diet 2. Practicing good hand washing 3. Avoiding live plants and fresh vegetables 4. Avoiding influenza vaccinations 5. Returning the child to school within six weeks Correct Answer: 1,2,3 Rationale 1: The child should be placed on calcium supplements to reduce the risk of osteopenia. Hand washing 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.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: The child should be placed on calcium supplements to reduce the risk of osteopenia. Hand washing 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.

Rationale 3: The child should be placed on calcium supplements to reduce the risk of osteopenia. Hand washing 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.

Rationale 4: The child can't return to school for 6 to 12 months after an HSCT. In-hospital or in-home schooling is required. The child and the family should be encouraged to get a yearly influenza vaccination.

Rationale 5: The child can't return to school for 6 to 12 months after an HSCT. In-hospital or in-home schooling is required. The child and the family should be encouraged to get a yearly influenza vaccination.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 20 Type: MCSA During a hurricane emergency, a child with hemophilia is injured and bleeding internally. The child is transported to the hospital. Due to the emergency, the appropriate factor is not available. What blood product would be the next best option to promote clotting?

1. Platelets 2. Whole blood 3. Packed cells 4. Fresh or fresh frozen plasma Correct Answer: 4 Rationale 1: The child has adequate platelets, and administration of platelets will not promote clotting.

Rationale 2: Whole blood will increase the blood volume without promoting clotting.

Rationale 3: A unit of packed cells will provide RBCs but not the factor needed to clot.

Rationale 4: Factors are located in the plasma. Fresh or fresh frozen plasma will provide the best source of factor available.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28-4 Question 21 Type: MCSA A ten-year-old boy with classic hemophilia is admitted to the hospital for hemorrhage into the knee joint.

Treatment is instituted on admission. What would be an appropriate nursing diagnosis for this child?

1. Risk for impaired physical mobility related to joint stiffness and contractures 2. Risk for impaired tissue perfusion (cerebral) related to blood loss.

3. Activity intolerance related to bleeding 4. Disturbed body image related to swollen knee Correct Answer: 1 Rationale 1: A bleed into the joint can lead to permanent contracture of the joint. Bone changes can result from the immobility associated with the bleed.

Rationale 2: Bleeding into the knee joint tends to be limited and decreased blood flow to the brain is unlikely.

Rationale 3: Activity intolerance is not the best diagnosis for this child.

Rationale 4: Although the knee will be swollen, body image is not the priority diagnosis at this time.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 28-6 Question 22 Type: MCMA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The nurse recommends to the mother of a 10-month-old child that cow’s milk not be introduced into the diet until after 12 months of age. The mother asks why she can’t switch to cow’s milk earlier. The nurse explains that cow’s milk can lead to iron deficiency anemia because: Standard Text: Select all that apply.

1. Cow’s milk is a poor source of iron.

2. The child may be exposed to an antibiotic in processed milk.

3. Cow’s milk has a high fat content.

4. In young children, cow’s milk can lead to bleeding from the gastrointestinal tract.

5. Cow’s milk contains no vitamin C, which is necessary for iron absorption.

Correct Answer: 1,4 Rationale 1: This information is correct.

Rationale 2: This would not be a rationale for delaying the entry of milk into the diet.

Rationale 3: Because there are low-fat varieties of cow’s milk, this would not be a reason to delay introducing it.

Rationale 4: This information is correct.

Rationale 5: While the amount of vitamin C in milk is limited, this is not the reason for delaying introducing cow’s milk into the child’s diet.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 23 Type: MCSA The nurse is preparing to administer a blood transfusion to a child with a severe anemia. Which type of transfusion reaction may be within the nurse’s realm of prevention?

1. Allergic 2. Hemolytic Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Febrile 4. Septic Correct Answer: 2 Rationale 1: Allergic reactions are due to a protein in the donated blood to which the child reacts. The nurse cannot prevent this type of reaction.

Rationale 2: A hemolytic reaction results from mismatched blood, a preventable error. This error is most likely to occur at the bedside if the nurse does not carefully identify the unit of blood and the patient.

Rationale 3: A febrile reaction is related to contamination of blood. The nurse has no control over this type of reaction.

Rationale 4: Septic is another name for a febrile reaction and is not preventable by the nurse.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 24 Type: MCSA The physician has ordered the child to receive a unit of packed red blood cells. In preparing to administer the blood, the nurse will initiate an intravenous line and hang what fluid?

1. D5W 2. D5LR 3. D5 1/4NS 4. NS Correct Answer: 4 Rationale 1: Dextrose should not be hung as it will cause packed cells to clot.

Rationale 2: D5 lactated Ringer solution also contains dextrose and should not be hung with packed cells.

Rationale 3: Dextrose is inappropriate no matter what is the other component of the intravenous fluids.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: Normal saline is appropriate to hang prior to initiating blood.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-6 Question 25 Type: MCMA A seven-year-old child is admitted in sickle-cell crisis. The nurse is concerned with reducing the child’s pain.

Recognizing that any activity that reduces the sickling will reduce the pain, nursing activities will include: Standard Text: Select all that apply.

1. Administration of narcotics.

2. Administration of NSAIDs. 3. Cold application.

4. Encouraging oral fluids.

5. Maintaining bed rest.

Correct Answer: 1,2,4,5 Rationale 1: Narcotics, such as morphine, are used to control the pain and reduce sickling.

Rationale 2: NSAIDs may be used in combination with narcotics to control the pain.

Rationale 3: Cold application is inappropriate in this situation as it would increase the sickling.

Rationale 4: Oral fluids will help “thin” the blood and reduce sickling.

Rationale 5: Bed rest will reduce the oxygen requirements of the body and prevent further sickling.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: Question 26 Type: MCSA Following treatment for iron deficiency anemia, the physician orders lab tests. Which lab value would indicate an improvement in the child’s condition?

1. Low hemoglobin 2. Normal platelet count 3. High reticulocyte count 4. Low hematocrit Correct Answer: 3 Rationale 1: Low hemoglobin is a typical finding in iron deficiency anemia.

Rationale 2: Platelet count is unrelated to iron deficiency anemia.

Rationale 3: Reticulocytes are immature red blood cells and indicate new cells are being produced.

Rationale 4: This would be a typical finding in iron deficiency anemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28-2

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Ball, Child Health Nursing, 3/E Chapter 29 Question 1 Type: MCSA A child has been diagnosed with a Wilms' tumor and is being treated with chemotherapy. Prior to administering the chemotherapy, what will the nurse monitor to determine if the child has any capability of fighting infection?

1. Hemoglobin 2. Red blood cell count 3. Platelets 4. Absolute neutrophil count (ANC) Correct Answer: 4 Rationale 1: Hemoglobin indicates oxygen-carrying capacity, not immune response.

Rationale 2: Red blood cell count has no correlation with immune function.

Rationale 3: Platelets are associated with clotting, not immune function.

Rationale 4: The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body's infection-fighting capability.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-2 Question 2 Type: MCMA Manifestations of cancer in the pediatric patient vary by type and location but typically include which of the following general manifestations?

Standard Text: Select all that apply.

1. Infection Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Weight gain 3. Polycythemia 4. Neurologic symptoms 5. Pain 6. Cachexia Correct Answer: 1,4,5,6 Rationale 1: Infection related to decreased immune function is common.

Rationale 2: Weight gain is incorrect; children with cancer are generally anorexic, have nausea and vomiting, and have early satiety.

Rationale 3: Anemia occurs rather than polycythemia.

Rationale 4: Neurologic symptoms can occur from impingement on the brain or nervous system.

Rationale 5: Pain results from neoplasms directly or indirectly affecting nerve receptors.

Rationale 6: Cachexia occurs secondarily to anorexia and nausea and vomiting.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-1 Question 3 Type: MCSA 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 response would be most therapeutic?

1. "You may feel guilty, but you should not blame yourself."

2. "Most cancers can be treated easily."

3. "Many types of cancer are difficult to diagnose and might not show early symptoms."

4. "Early diagnosis is not significant in the diagnosis and management of cancer."

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: This is not a therapeutic response. It is not appropriate for the nurse to tell the family how they should feel.

Rationale 2: This answer is not accurate, as cancer is generally prolonged and difficult for both the child and family.

Rationale 3: Many cancers do not present significant findings until late and can progress rapidly. Giving such information is a communication tool.

Rationale 4: Outcomes for many cancers are improved with early diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-1 Question 4 Type: MCSA A child has cancer and has been treated with chemotherapy. The most recent lab value indicates that the white blood cell count is very low. Based on this result, which would the nurse expect to administer?

1. Epoetin alfa (Epogen) 2. Ondansetron (Zofran) 3. Oprelvekin (Neumega) 4. Filgrastim (Neupogen) Correct Answer: 4 Rationale 1: Epoetin alfa (human recombinant erythropoietin) stimulates red blood cell (RBC) production.

Rationale 2: Ondansetron (Zofran) is an antiemetic.

Rationale 3: Oprelvekin (Neumega) increases platelets.

Rationale 4: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-2 Question 5 Type: MCSA 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 what levels?

1. Specific gravity 1.030 and pH 7.5 2. Specific gravity 1.005 and pH 6 3. Specific gravity 1.030 and pH 6 4. Specific gravity 1.005 and pH 7.5 Correct Answer: 4 Rationale 1: A specific gravity higher than 1.010 can mean fluid intake is not high enough.

Rationale 2: A pH of less than 7 means acidosis.

Rationale 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.

Rationale 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 to 7.Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-2 Question 6 Type: MCSA The antiemetic drug ondansetron (Zofran) is being administered to a child receiving chemotherapy. It should be administered: 1. Only if the child experiences nausea.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Before chemotherapy administration, as a prophylactic measure.

3. After the chemotherapy has been administered.

4. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.

Correct Answer: 2 Rationale 1: Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea.

Rationale 2: The antiemetic ondansetron (Zofran) should be administered before chemotherapy and every four hours during the administration of chemotherapy, as a prophylactic measure.

Rationale 3: Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea.

Rationale 4: It is the drug of choice for controlling nausea caused by chemotherapy agents.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29-2 Question 7 Type: MCSA A child has thrombocytopenia secondary to chemotherapy treatments. Based on this finding, what should the nurse do?

1. Avoid administering intramuscular injections (IM).

2. Monitor intake and output.

3. Use palpation as a component of assessment.

4. Avoid performing oral hygiene.

Correct 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.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: Intake and output should be measured for all children receiving chemotherapy but not due to the thrombocytopenia.

Rationale 3: Gentle palpation should still be included in physical assessments unless a Wilms' tumor has been diagnosed or is suspected. However, it is not related to the thrombocytopenia.

Rationale 4: Oral hygiene care should be done with a soft toothbrush.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-3 Question 8 Type: MCSA 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 symptoms should the nurse monitor this child?

1. Respiratory distress and cyanosis 2. Thrombocytopenia and leukocytosis 3. Oliguria and altered levels of consciousness 4. Upper-extremity edema and neck vein distension Correct Answer: 3 Rationale 1: Respiratory distress and cyanosis would be associated with space-occupying lesions or a hematologic emergency.

Rationale 2: Thrombocytopenia and leukocytosis occur with a hematological emergency.

Rationale 3: 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.

Rationale 4: Upper-extremity edema and neck vein distension are not priority concerns for this client.

Global Rationale:

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Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-3 Question 9 Type: MCSA 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 don't have any pain, so I won't need to take the leucovorin this time."

2. "I don't have any nausea, so I won't need the leucovorin."

3. "I'm glad I only need one dose of the leucovorin."

4. "It is important that I receive my leucovorin on time as it protects my body from the methotrexate.”

Correct Answer: 4 Rationale 1: Leucovorin is not administered for pain.

Rationale 2: Leucovorin is administered for nausea.

Rationale 3: One dose is not the recommended therapy.

Rationale 4: 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.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 29-4 Question 10 Type: MCSA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

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. Unexpected; the cancer is easily treated.

3. Unusual; the illness doesn't affect the sibling.

4. Normal; the sibling is affected, too, and anger and guilt are expected feelings.

Correct Answer: 4 Rationale 1: Siblings are generally affected to some degree, but this a normal reaction.

Rationale 2: Cancer is not easily treated and will affect the entire family.

Rationale 3: A diagnosis of cancer affects the entire family; siblings will be affected to some degree.

Rationale 4: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling might be anger and guilt.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-5 Question 11 Type: MCMA A child is receiving chemotherapy induction for acute lymphocytic leukemia (ALL). Taking common side effects into consideration, which nursing diagnoses would be appropriate during the induction chemotherapy?

Standard Text: Select all that apply.

1. Risk for injury: hemorrhagic cystitis 2. Skin integrity: impaired mucous membrane 3. Fluid and electrolyte impairment: nausea and vomiting 4. Risk for infection Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

5. Impaired sleep pattern 6. Diarrhea Correct Answer: 1,2,3,6 Rationale 1: Hemorrhagic cystitis is a common early side effect of chemotherapy and is usually prevented with large amount of IV fluids to adequately protect the kidneys.

Rationale 2: Mouth sores are a common early side effect of chemotherapy and usually occur two to five days after the administration of chemotherapy.

Rationale 3: Nausea and vomiting are common early side effects of chemotherapy.

Rationale 4: Bone marrow suppression does not peak until 7 to 10 days post-induction. This nursing diagnosis would be appropriate at that time.

Rationale 5: Impaired sleep patterns are not directly related to chemotherapy.

Rationale 6: Diarrhea is a common early side effect of chemotherapy.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29-5 Question 12 Type: MCSA A child with leukemia has a granulocyte count of 250/mm3 and a platelet count 150,000/mm3. Nursing intervention would include which of the following?

1. Fluid restriction 2. Avoidance of mouth care 3. Strict isolation 4. Good hand washing Correct Answer: 4 Rationale 1: Fluids should continue to be encouraged.

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Rationale 2: Platelet count is normal; mouth care should include brushing with a soft toothbrush and frequent rinsing.

Rationale 3: The child should be isolated from anyone infectious, but strict isolation is not necessary.

Rationale 4: Hand washing is vital for preventing the spread of infection.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29-5 Question 13 Type: MCSA A child with rhabdomyosarcoma is to undergo radiation therapy after surgical removal of the tumor. The parents should be taught to: 1. Apply lotion to the area before radiation therapy.

2. Apply sunscreen to the area when the child is exposed to sunlight.

3. Remove any markings left after each radiation treatment.

4. Vigorously scrub the area when bathing the child.

Correct Answer: 2 Rationale 1: Lotion can increase the chance of a radiation burn when applied before the treatment.

Rationale 2: Radiation therapy causes the skin in that area to be sensitive. Sunscreen should be applied so that sunburns are avoided.

Rationale 3: Radiation markings are to guide the radiologist and should not be removed.

Rationale 4: Vigorous scrubbing is not recommended.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 29-6 Question 14 Type: MCSA The child has been admitted to the hospital unit newly diagnosed with retinoblastoma. What would the nurse expect to see when examining the child’s eye?

1. A white reflex 2. Blue-tinged sclera 3. A red reflex 4. Yellow sclera Correct Answer: 1 Rationale 1: The first sign of retinoblastoma is a white pupil. The red reflex is absent. This is known as leukocoria, or "cat's eye" reflex.

Rationale 2: Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

Rationale 3: Red reflex is absent in retinoblastoma.

Rationale 4: Yellow sclera is a sign of jaundice, not retinoblastoma.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-6 Question 15 Type: MCSA The nurse works in an oncology clinic. A preschool-age child is being seen in the clinic, and the nurse anticipates a diagnosis of cancer. The nurse prepares for which of the common reactions preschool-age children have following illnesses and hospitalizations?

1. Unawareness of the illness and its severity 2. Acceptance, especially if able to discuss the disease with children their own age Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Understanding of what cancer is and how it is treated 4. Thoughts that they caused their illness and are being punished Correct Answer: 4 Rationale 1: Infants and toddlers are unaware of the severity of the disease.

Rationale 2: Immediate acceptance will not occur with children of any age. Adolescents find contact with others who have gone through their experience helpful.

Rationale 3: School-age children can understand a diagnosis of cancer.

Rationale 4: Preschool-age children are egocentric and have magical thinking, and thus they might believe they caused their own illness.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-7 Question 16 Type: MCSA After years of treatment with chemotherapy and radiation, a child with a brain tumor is shown to be refractory to treatment, and a DNR (Do Not Resuscitate) has been obtained. The mother has reached the stage of acceptance; the father is angry that the medical and nursing team has not been able to "save" his child. How would the multidisciplinary team best support this family?

1. Tell the father that he should have brought his child in earlier for treatment.

2. Continue to include the family in planning care and assure them that the child will be kept comfortable in the days to come.

3. Initiate a Social Services referral.

4. Contact the on-call chaplain for consultation with the entire family and ask him to take the father aside for additional assistance.

Correct Answer: 2 Rationale 1: Increasing the father's sense of guilt will not help diminish his anger.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 2: Being informed and involved will be the best way to assist the father at this point. Families also might need repeated and ongoing reassurances throughout the death process.

Rationale 3: This is not within the scope of Social Services.

Rationale 4: Isolating the father would only increase his anger and make him feel belittled. Contacting the chaplain would be appropriate if the family desired this.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-8 Question 17 Type: MCSA During rounds, the interdisciplinary team is discussing the care of a child with a newly diagnosed Wilms' tumor.

The nurse describes the mother as being angry and upset that they are not caring properly for her child. What behavior probably is the cause of the mother's anger?

1. The mother is beginning the stages of grief over loss of her previously well child.

2. The mother is feeling guilty for not recognizing that the child was ill.

3. The nurses are negligent in providing safe care for the child.

4. The mother does not have adequate support from Social Services.

Correct Answer: 1 Rationale 1: Anger is the first stage of the grief process and can be applied in this instance to the mother's loss of a normal child and potential death.

Rationale 2: This is not evident in the question Rationale 3: The mother is in the anger stage of grief, and it is not reflective of the nursing care.

Rationale 4: This is not evident in the question.

Global Rationale: Cognitive Level: Analyzing Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-8 Question 18 Type: MCSA The nurse is explaining to the mother that her child with cancer will receive chemotherapy daily for one month and then no treatments for six weeks. Following the period of rest, chemotherapy will be administered again for another month. The mother asks why the child can’t receive the medication for two months straight. The nurse would explain that the rest period: 1. Prevents the child from having side effects from the drugs.

2. Is due to the scheduling requirements of the infusion center.

3. Is necessary because receiving the medication for more than one month can cause heart failure.

4. Allows normal cells to repair themselves while the cancer cells die.

Correct Answer: 4 Rationale 1: The child will have side effects from the beginning of treatment.

Rationale 2: This is incorrect information. Necessary treatment should never be delayed for the convenience of the medical personnel.

Rationale 3: This is incorrect information.

Rationale 4: Cancer cells have lost the ability to repair themselves, so medications allow the normal cells to repair while the cancer cells die.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 19 Type: MCSA A child has been diagnosed with Ewing sarcoma and is being started on a chemotherapy protocol. The mother questions the nurse on why more than one drug is being used as it would seem that using fewer drugs would decrease the side effects. The best response by the nurse would include the information that: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. The child’s cancer is a severe form and needs additional drugs to remove the cancer.

2. A protocol is a proven means of treatment.

3. A protocol is used in children but not adults due to the chemotherapy’s effect on growth.

4. A protocol involves a group of drugs that work in different modes and have different side effects.

Correct Answer: 4 Rationale 1: This is not the reason that a protocol is utilized.

Rationale 2: While this information is correct, it does not explain why a protocol is chosen instead of a single drug therapy.

Rationale 3: Protocols are used on children and adults.

Rationale 4: A combination of chemotherapy will be more effective with a lessening of the side effects.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-4 Question 20 Type: MCSA Following diagnosis of osteosarcoma, a 14-year-old girl has a below-the-knee amputation. The girl has had trouble accepting the reality of her amputation. Which behavior, when observed by the nurse, indicates she is beginning to accept the amputation?

1. The girl complains of pain in the missing leg.

2. When physical therapy comes, she is willing to have her temporary prosthetic applied and attempts crutch training.

3. Prior to visiting hours, she asks to be helped to a wheelchair with a blanket over her legs.

4. When the nurses change the dressing on the stump, she watches the dressing change.

Correct Answer: 4

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Rationale 1: The pain she describes is known as phantom pain; it is an expected finding but does not indicate acceptance of the amputation.

Rationale 2: This indicates she wants to return to mobility but has not yet accepted the stump.

Rationale 3: Being in a wheelchair with a blanket cover indicates she doesn’t want her friends to be aware of her amputation.

Rationale 4: This indicates the girl is willing to look at the stump, which is a step toward acceptance.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 29-7 Question 21 Type: MCSA A five-year-old child is on chemotherapy for rhabdomyosarcoma. Despite antiemetics, the child complains of nausea. The mother wants the child to eat and is pushing the child to eat the food. The nurse would talk with the mother and suggest that she not push the food on the nauseated child because: 1. The child does not need to eat as he is on intravenous fluids.

2. Forcing the child to eat may lead to a food aversion for the child.

3. Vomiting can lead to damage to the stomach.

4. Pushing the child to eat leads to a psychological conflict that may turn the child away from the parent.

Correct Answer: 2 Rationale 1: Intravenous fluids do not replace normal food intake.

Rationale 2: If the child is forced to eat and then vomits, the child can develop a food aversion in which the child associates that food with vomiting.

Rationale 3: Vomiting is unpleasant but does not usually lead to stomach damage.

Rationale 4: This is not a correct statement. Parents and children often disagree, but the child will still relate to the parent.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-7 Question 22 Type: MCSA The ten-year-old child was diagnosed with a medulloblastoma; following surgery the child is started on chemotherapy by intrathecal injection. While preparing the family for the start of chemotherapy, the nurse will explain that intrathecal administration was chosen because: 1. It reduces side effects.

2. It does not require the child being “stuck.”

3. Many chemotherapy drugs do not cross the blood-brain barrier.

4. Intrathecal administration is less expensive than intravenous administration.

Correct Answer: 3 Rationale 1: Intrathecal administration does not reduce side effects.

Rationale 2: Intrathecal administration is through a spinal tap, so the child will be “stuck” for administration.

Rationale 3: This is the correct rationale for the selection of intrathecal administration of chemotherapy.

Rationale 4: This is not accurate and would not be a reason to change administration modes.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-2 Question 23 Type: MCMA The 10-year-old boy is admitted to the pediatric neurologic unit with a suspected craniopharyngioma. The nurse will assess the child with which symptoms related to this brain tumor?

Standard Text: Select all that apply.

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1. Evening nausea 2. Excessive urination leading to dehydration 3. Nystagmus 4. Headaches 5. Orbital ecchymosis Correct Answer: 2,3,4 Rationale 1: Nausea is a common symptom of a brain tumor due to effect on the vomiting center of the brain.

However, it occurs primarily in the morning on arising.

Rationale 2: Diabetes insipidus is common in tumors involving the pituitary gland, such as craniopharyngioma.

Rationale 3: Nystagmus is a symptom of pressure on the optic nerve chiasm.

Rationale 4: The headaches may be due to the increased bulk in the cranium and/or the ventricular blockage leading to hydrocephalus.

Rationale 5: Orbital ecchymosis is seen in neuroblastoma secondary to metastasis to the bone.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-7 Question 24 Type: MCMA Following diagnosis of Ewing’s sarcoma, the physician orders chemotherapy for the 12-year-old child. After discussion with the physician, the parents refuse a central line so the chemotherapy will be administered by peripheral line. The nurse will prevent extravasation by: Standard Text: Select all that apply.

1. Ensuring that the intravenous line is a free flowing line.

2. Administering the medication by infusion pump.

3. Checking for blood return before and during chemotherapy administration.

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4. Diluting the medication with normal saline.

5. Administering the vesicant drug last.

Correct Answer: 1,3 Rationale 1: This is critical as extravasation is leaking into the tissues.

Rationale 2: An infusion pump does not ensure that the line is free flowing; this is inappropriate.

Rationale 3: This checks for intravenous administration and is appropriate.

Rationale 4: Not all medications can be mixed with normal saline, and this does not protect against extravasation.

Rationale 5: The vesicant drug should be administered first.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-3

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Ball, Child Health Nursing, 3/E Chapter 30 Question 1 Type: MCSA A child with inflammatory bowel disease is taking prednisone daily. The family should be taught to administer the prednisone at what time?

1. Between meals 2. At bedtime 3. One hour before meals 4. With meals Correct Answer: 4 Rationale 1: Prednisone can cause gastric irritation and should not be given on an empty stomach.

Rationale 2: Prednisone can cause gastric irritation and should not be given on an empty stomach.

Rationale 3: Prednisone can cause gastric irritation and should not be given on an empty stomach.

Rationale 4: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-5 Question 2 Type: MCSA A three-year-old child is suspected of having Hirschsprung's disease. Which assessment factors would support such a medical diagnosis?

1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea Correct Answer: 3 Rationale 1: Clay-colored stools and dark urine are not associated with Hirschsprung's disease.

Rationale 2: The infant with Hirschsprung’s disease often has delayed meconium stools.

Rationale 3: These are symptoms of Hirschsprung's disease in an older infant or child.

Rationale 4: Diarrhea is not typical; obstruction is more likely.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-3 Question 3 Type: MCSA An adolescent complains of recurrent abdominal pain with diarrhea and bloody stools. The nurse should recognize these as symptoms of which inflammatory bowel disease?

1. Necrotizing enterocolitis 2. Ulcerative colitis 3. Crohn's disease 4. Appendicitis Correct Answer: 2 Rationale 1: Necrotizing enterocolitis is usually seen in premature infants and generally not in an adolescent patient.

Rationale 2: Diarrhea and bloody stools are typical symptoms of UC. Rationale 3: The teen with Crohn's disease might have abdominal pain and diarrhea, but stools usually do not have blood in them.

Rationale 4: Appendicitis is not associated with bloody stools and usually not with diarrhea.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-3 Question 4 Type: MCSA The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth.

1. Below the umbilicus 2. Just below the sternum 3. Just above the pubic bone 4. Just above the umbilicus, around the largest circumference of the abdomen Correct Answer: 4 Rationale 1: The circumference below the umbilicus, just below the sternum, or above the pubic bone would not be an accurate abdominal girth.

Rationale 2: The circumference below the umbilicus, just below the sternum, or above the pubic bone would not be an accurate abdominal girth.

Rationale 3: The circumference below the umbilicus, just below the sternum, or above the pubic bone would not be an accurate abdominal girth.

Rationale 4: An abdominal girth should be taken around the largest circumference of the abdomen, just above the umbilicus.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-5 Question 5 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The nurse is planning postoperative care for an infant after a cleft lip repair. Which intervention should the nurse include in this infant's plan of care?

1. Suctioning with a tonsil tip (Yankauer) device 2. Using a pacifier to reduce straining the suture line with crying 3. Supine positioning 4. Frequent breast or bottle feeding Correct Answer: 3 Rationale 1: A tonsil tip (Yankauer) suction device is made of hard plastic, and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft-suction catheter.

Rationale 2: The child is not allowed to have anything in her mouth, so pacifiers are not acceptable. The child should be soothed by holding and cuddling.

Rationale 3: Integrity of the suture line is essential for postoperative care of cleft lip repair. The infant should be placed in a supine position to avoid rubbing the suture line on the bedding.

Rationale 4: In the immediate postoperative period, the child is fed by eye dropper or rubber-tipped asepto syringe to prevent damage to the suture line.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30-4 Question 6 Type: MCSA An infant has been born with an esophageal atresia and tracheoesophageal fistula. What is a priority preoperative nursing diagnosis?

1. Ineffective tissue perfusion: gastrointestinal, related to decreased circulation 2. Ineffective infant feeding pattern related to uncoordinated suck and swallow 3. Acute pain related to esophageal defect 4. Aspiration, risk for related to regurgitation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 4 Rationale 1: Tissue perfusion is not a primary problem with this condition.

Rationale 2: The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply.

Rationale 3: Pain is not usually experienced preoperatively with this condition.

Rationale 4: This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea.

Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 30-5 Question 7 Type: MCSA An infant born with an omphalocele defect is being admitted to the intensive care nursery. Which of the following should the nurse in charge instruct the nursing technician to prepare?

1. Radiant warmer 2. Crib 3. Bilirubin light 4. Formula for feeding Correct Answer: 1 Rationale 1: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant loses heat through the viscera; a warmer is indicated to prevent hypothermia.

Rationale 2: The crib would not provide adequate maintenance of temperature control.

Rationale 3: The need for a bilirubin light is not directly related to an abdominal wall defect.

Rationale 4: The infant is NPO (nothing by mouth) preoperatively.

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Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30-5 Question 8 Type: MCSA The nurse is preparing to ambulate an 11-year-old child who has had an appendectomy. In addition to pharmacological pain management, which of the following nonpharmacologic, independent nursing pain management strategies would be appropriate for this child?

1. A warm, moist pack 2. EMLA cream to the incision site 3. An ice pack 4. A splint pillow against the abdomen when moving or coughing Correct Answer: 4 Rationale 1: Heat and moisture are not used on the incision area, as they can impair the healing process of the wound.

Rationale 2: EMLA cream is a medication that requires a medical order.

Rationale 3: Heat and ice are not used on the incision area, as they can impair the healing process of the wound.

Rationale 4: A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-5 Question 9 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Which statement indicates that parents have understood the nurse's teaching with regard to colostomy stoma care for their toddler?

1. "We will change the colostomy bag with each wet diaper."

2. "We will expect a moderate amount of bleeding after cleansing the area around the stoma."

3. "We will watch for skin irritation around the stoma."

4. "We will use adhesive enhancers when we change the bag."

Correct Answer: 3 Rationale 1: Physical or chemical skin irritation can occur if the appliance is changed too frequently, or with each wet diaper.

Rationale 2: Bleeding is usually attributable to excessive cleaning.

Rationale 3: Skin irritation around the stoma should be assessed; it could indicate leakage.

Rationale 4: Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 30-6 Question 10 Type: MCSA A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse prepare for use?

1. Appropriate bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Equipment for intubation Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: A bag-valve-mask or ambu bag could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing.

Rationale 2: The defect is not external, so sterile gauze and saline are not needed.

Rationale 3: Soft arm restraints might be necessary but at are not an immediate concern.

Rationale 4: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-6 Question 11 Type: MCSA A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which nursing intervention would the nurse omit from the plan of care for this child?

1. NPO status until bowel sounds return 2. Frequent assessment of the surgical site 3. Avoiding narcotics to prevent depression of the respiratory system 4. Allow parents at the bedside as soon as possible.

Correct Answer: 3 Rationale 1: This is standard postoperative care.

Rationale 2: The surgical site must be visualized frequently for bleeding.

Rationale 3: Pain management is essential and narcotic medications will be used. The nurse will monitor the respiratory status, but it is inappropriate to withhold pain management.

Rationale 4: This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30-6 Question 12 Type: MCMA At delivery, it was discovered that the newborn had a bilateral cleft lip. The parents are distressed about the appearance of their infant. Nursing behaviors that can help the parents bond to the infant include: Standard Text: Select all that apply.

1. Calling the infant by name when referring to the infant.

2. Keeping the infant’s lower face covered with the blanket.

3. Smiling at the infant and talking to the infant in the parents’ presence.

4. Showing the parents before and after pictures of other children with cleft lips.

5. Discussing positive features of their baby.

Correct Answer: 1,3,4,5 Rationale 1: This behavior humanizes the child to the parents and is appropriate.

Rationale 2: This indicates that the infant’s appearance is distressing. Although the nurse would want to shield the child from a visitor’s stare, the nurse would not want to hide the child from her own family.

Rationale 3: This indicates acceptance of the infant by the nurse.

Rationale 4: It is usually not appropriate to show before and after pictures as you cannot predict the success of the surgery on this child. But in the case of cleft lip, the improvement will be significant and it is considered acceptable to show before and after pictures.

Rationale 5: Statements like “Your baby is the sweetest thing—she never cries,” can help the parents recognize positive features about their baby.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 30-6 Question 13 Type: MCSA The woman has a normal pregnancy except for polyhydramnios. The delivery goes well and the baby is born and receives APGAR scores of seven and nine. Upon admission to the newborn nursery, the nurse is unsuccessful in inserting a nasogastric tube. The infant is suspected of having an esophageal atresia/tracheoesophageal fistula.

While waiting for the pediatrician to see the infant, the nurse should: 1. Position the infant in semi-Fowler position.

2. Allow the infant to be taken to the mother’s room for bonding.

3. Offer the infant formula feeding instead of breastfeeding.

4. Wrap the infant in blankets and place in a crib by the viewing window.

Correct Answer: 1 Rationale 1: This will reduce stomach juices from being aspirated into the lungs.

Rationale 2: Because an anomaly is suspected, the infant should remain under visualization until the diagnosis is confirmed and medical orders determined.

Rationale 3: If an EA/TE fistula is suspected, the feeding should be withheld until the diagnosis is confirmed or cleared.

Rationale 4: An infant wrapped in blankets cannot be observed clearly. The child should be placed in an over-bed warmer.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-5 Question 14 Type: MCSA A nasogastric tube to suction is ordered for a child newly diagnosed with a diaphragmatic hernia. The nurse notes that the surgeon has not ordered fluid replacement for the NG drainage. What might occur if large amounts of gastric drainage are noted without replacement?

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1. The infant may lose weight due to loss of nutrition.

2. The infant will develop metabolic alkalosis.

3. The infant will become dehydrated.

4. The infant will develop hyperbilirubinemia.

Correct Answer: 2 Rationale 1: The child is NPO. Weight loss and inadequate nutrition are not related to lack of NG replacement.

Rationale 2: When large quantities of gastric juice is removed, acid is lost and metabolic alkalosis follows.

Rationale 3: The volume would not be sufficient to cause dehydration.

Rationale 4: Hyperbilirubinemia is unrelated to gastric suction.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-3 Question 15 Type: MCMA Following diagnosis of Crohn’s disease, the nurse is explaining dietary modifications to the teenagers. The nurse would recommend: Standard Text: Select all that apply.

1. Increased fiber in the diet to promote solid stools.

2. Small, frequent feedings are preferred over three meals a day.

3. Identify foods that cause distress and eliminate them from the diet.

4. High-calorie dietary supplement shakes can help meet nutritional requirements.

5. Socialization is important at mealtime no matter the dynamics.

Correct Answer: 2,3,4 Rationale 1: Fiber should be decreased, not increased, as diarrhea is one of the symptoms of Crohn’s disease.

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Rationale 2: This is correct information.

Rationale 3: This is individualizing the diet and is appropriate.

Rationale 4: This addition provides an easy way to meet the nutritional needs.

Rationale 5: Stress should be avoided at mealtimes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-6 Question 16 Type: MCSA Following hospital discharge for treatment of gastroesophageal reflux, the home health nurse visits the family.

Which finding made by the nurse during the visit requires the nurse to intervene?

1. The infant’s formula has rice cereal added.

2. The mother hold the infant is a high Fowler’s position while feeding.

3. After feeding, the infant is placed in an infant seat.

4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.

Correct Answer: 3 Rationale 1: Rice cereal thickens the formula and helps prevent regurgitation. This is appropriate.

Rationale 2: This position will help prevent regurgitation and is appropriate.

Rationale 3: Infant seats are not recommended as they put pressure on the abdomen and may contribute to regurgitation.

Rationale 4: Since dosing is small, it is appropriate to use a syringe for accurate measurement.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 30-6 Question 17 Type: MCSA A woman pregnant at term arrives at the small rural hospital in active labor. She has received no prenatal care. At delivery, it is discovered that the newborn has a gastroschisis defect. Immediate transfer to a pediatric hospital is planned. Nursing care to prepare the infant for discharge would include: 1. Covering the exposed intestines with sterile moist gauze.

2. Wrapping the infant warmly in two or three blankets.

3. Providing a sterile water feeding to maintain hydration during transport.

4. Preventing the parents from seeing the infant prior to transfer to reduce their anxiety.

Correct Answer: 1 Rationale 1: It is important to keep the intestine from drying during transport.

Rationale 2: Placement in a transport isolette would be preferred to wrapping due to the nature of his birth defect.

Rationale 3: The infant should be NPO. Rationale 4: The parents should be informed of the child’s defect and allowed to see and hold the infant if the infant’s condition allows.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30-5 Question 18 Type: MCSA A toddler is admitted to the surgical unit for planned closure of the temporary colostomy. The nurse completes the admission assessment and reviews the medical orders. Which order should the nurse question?

1. Clear liquids today. NPO tomorrow 2. Type and cross-match for one unit of packed red blood cells.

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3. Rectal temperatures every four hours 4. Start an intravenous line with D5NS at 20 ml per hour.

Correct Answer: 3 Rationale 1: This is appropriate in anticipation of surgery.

Rationale 2: Although not always required during surgery, this would not be inappropriate planning for the surgical procedure.

Rationale 3: Rectal temperatures are avoided due to the fragile state of the rectum.

Rationale 4: An IV is appropriate for surgical access.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30-5 Question 19 Type: MCMA The nurse who works in the newborn nursery must be alert for infants with congenital gastrointestinal defects.

Defects that might be diagnosed in the newborn nursery would include: Standard Text: Select all that apply.

1. Pyloric stenosis.

2. Biliary atresia.

3. Hirschsprung’s disease.

4. Umbilical hernia.

5. Diaphragmatic hernia.

Correct Answer: 3,5 Rationale 1: Pyloric stenosis is not diagnosed in the newborn nursery, but in the two- to four-week-old infant.

Rationale 2: Symptoms of biliary atresia would not be observable until several weeks of age.

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Rationale 3: Symptoms of Hirschsprung’s disease may be observable in the newborn nursery.

Rationale 4: Umbilical hernia cannot be diagnosed at birth.

Rationale 5: Diaphragmatic hernia will show symptoms immediately after birth due to compression of the lung.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-3

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Ball, Child Health Nursing, 3/E Chapter 31 Question 1 Type: MCSA A child has been admitted to the hospital unit with a diagnosis of minimal change nephrotic syndrome (MCNS).

The clinical manifestations will include which of the following?

1. Massive proteinuria, hypoalbuminemia, and edema 2. Hematuria, bacteriuria, and weight gain 3. Urine-specific gravity decreased and urinary output increased 4. Gross hematuria, albuminuria, and fever Correct Answer: 1 Rationale 1: Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema.

Rationale 2: Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen.

Rationale 3: In MCNS, the urine output decreases and the specific gravity of urine increases.

Rationale 4: Gross hematuria and hypertension are associated with glomerulonephritis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 2 Type: MCSA A child with nephritic syndrome is severely edematous. The primary health care provider has placed the child on bed rest. An important nursing intervention for this child would be to: 1. Monitor BP every 30 minutes.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Reposition the child every two hours.

3. Limit visitors.

4. Encourage fluids.

Correct Answer: 2 Rationale 1: Vital signs are taken every four hours.

Rationale 2: A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every two hours.

Rationale 3: The child needs social interaction, so visitors should not be limited.

Rationale 4: Fluids need to be monitored; they should not be encouraged.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-1 Question 3 Type: MCSA A child is admitted with acute glomerulonephritis. The nurse would expect the urinalysis during this acute phase to show which of the following?

1. Bacteriuria and increased specific gravity 2. Hematuria and proteinuria 3. Proteinuria and decreased specific gravity 4. Bacteriuria and hematuria Correct Answer: 2 Rationale 1: Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present.

But because the urine is concentrated, the specific gravity is increased.

Rationale 2: Glomerulonephritis is an inflammation of the glomeruli of the kidneys. The clinical manifestation of glomerulonephritis is grossly bloody hematuria with mild to moderate proteinuria, and because the urine is concentrated, the specific gravity is increased.

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Rationale 3: Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Because the urine is concentrated, the specific gravity is increased.

Rationale 4: Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 4 Type: MCSA A four-year-old has acute glomerulonephritis (AGN) and is admitted to the hospital. The priority nursing diagnosis for this child would be: 1. Risk for injury related to hypertension.

2. Altered growth and development related to a chronic disease.

3. Risk for infection related to hypertension.

4. Fluid volume excess related to decreased plasma filtration.

Correct Answer: 1 Rationale 1: The child with AGN has marked hypertension, which can lead to cardiac failure and cerebral injuries.

Rationale 2: Growth and development are not normally affected because this is an acute process, not a chronic one.

Rationale 3: While a risk for infection might be present, it is not related to the hypertension.

Rationale 4: Although fluid retention occurs, this is not the priority diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 31-1 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 5 Type: MCSA A nurse is preparing to admit a child with possible obstructive uropathy. What labs should the nurse expect to draw on this child?

1. Platelet count 2. Blood urea nitrogen (BUN) and creatinine 3. Partial thromboplastin time (PTT) 4. Blood culture Correct Answer: 2 Rationale 1: Platelet count is drawn when a bleeding disorder is suspected Rationale 2: The blood urea nitrogen (BUN) and creatinine are serum lab tests for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN and creatinine will be elevated.

Rationale 3: Partial thromboplastin time (PTT) is drawn when a bleeding disorder is suspected.

Rationale 4: A blood culture is done when an infectious process is suspected.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31-2 Question 6 Type: MCSA Which sets of symptoms are characteristic of a preschool-age child with a urinary tract infection?

1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure, and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: Hematuria might be present, but there will be no complaints of headache or vertigo.

Rationale 2: While foul-smelling urine and hematuria can be present, there is no elevated BP, headache, or vertigo.

Rationale 3: Clinical manifestations of a urinary tract infection (UTI) in a preschool-age child include fever, urgency, and dysuria.

Rationale 4: There could be flank pain, although the preschooler might be unable to describe it. There will be no complaints of headache.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-2 Question 7 Type: MCSA A child has undergone a kidney transplant and is receiving cyclosporine. The parents ask the nurse about the reason for the cyclosporine. The nurse should explain that the drug is given to: 1. Suppress rejection.

2. Decrease pain.

3. Improve circulation.

4. Boost immunity.

Correct Answer: 1 Rationale 1: Cyclosporine is given to suppress rejection.

Rationale 2: Cyclosporine doesn't decrease pain.

Rationale 3: Cyclosporine doesn't affect circulation.

Rationale 4: Cyclosporine doesn't boost immunity.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-7 Question 8 Type: MCSA A child in renal failure has hyperkalemia. The nurse plans to instruct the child and her parents to avoid which foods?

1. Carrots and green, leafy vegetables 2. Spaghetti and meat sauce with breadsticks 3. Hamburger on a bun and cherry gelatin 4. Chips, cold cuts, and canned foods Correct Answer: 1 Rationale 1: Carrots and green, leafy vegetables are high in potassium.

Rationale 2: Spaghetti and meat sauce with breadsticks would be acceptable choices for a low-potassium diet.

Rationale 3: Hamburger on a bun with cherry gelatin would be acceptable choices for a low-potassium diet.

Rationale 4: Chips, cold cuts, and canned foods are high in sodium but not necessarily in potassium.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31-5 Question 9 Type: MCSA A child is scheduled for a kidney transplant. The nurse has completed the preoperative teaching to prepare the child and parents for the surgery and postoperative considerations. Which statement indicates that the parents understand the process involved with a kidney transplant?

1. "We're happy our child won't have to take any more medicine after the transplant."

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2. "We understand our child won't be at risk anymore for catching colds from other children at school."

3. "We'll be glad we won't have to bring our child in to see the doctor again."

4. "We know it's important to see that our child takes prescribed medications after the transplant."

Correct Answer: 4 Rationale 1: Medications and general health promotion will be necessary.

Rationale 2: The child will be on immunosuppressing drugs and will be at increased risk for colds and other illnesses.

Rationale 3: Follow-up appointments will be necessary, as well as medications and general health promotion.

Rationale 4: It is important that the nurse emphasizes compliance with treatments that will need to be followed after the transplant.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 31-6 Question 10 Type: MCMA A child is undergoing hemodialysis. The child should be monitored closely for: Standard Text: Select all that apply.

1. Migraines.

2. Hypotension.

3. Infections.

4. Fluid overload.

5. Shock.

Correct Answer: 2,3,5 Rationale 1: Migraines are not a clinical manifestation associated with hemodialysis.

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Rationale 2: Rapid changes in fluid and electrolyte balance during hemodialysis can lead to hypotension.

Rationale 3: Infection is another complication that may occur during hemodialysis.

Rationale 4: Fluid overload is not a clinical manifestation associated with hemodialysis.

Rationale 5: Rapid changes in fluid and electrolyte balance during hemodialysis can lead to shock.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-7 Question 11 Type: MCSA Following a hypospadias repair, the 10-month-old child returns from the operating room with a urethral stent. It is now four hours since the child’s surgery. Which assessment finding should be reported to the surgeon?

1. The infant has bloody urine.

2. The infant has voided one time since returning from surgery.

3. The infant seems to be having bladder spasms that respond favorably to anticholinergic medications.

4. Double diapering the infant has resulted in the stent being free from stool contamination.

Correct Answer: 2 Rationale 1: Bloody urine is expected in the immediate postoperative period.

Rationale 2: A 10-month-old will void more often than one time in four hours. This could indicate the stent is occluded. The surgeon should be notified.

Rationale 3: This is a normal finding.

Rationale 4: This is a desired finding and doesn’t need to be reported to the surgeon.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-3 Question 12 Type: MCMA The surgeon is discussing plans for orchiopexy with the parents of an infant born with cryptorchidism. The parents are overwhelmed and do not hear much of the discussion. The nurse will clarify the surgeon’s explanation by discussing that the risk of undescended testes include: Standard Text: Select all that apply.

1. Sperm production will be affected after puberty.

2. Abdominal testes are subject to injury.

3. Abdominal testes have a higher risk of developing cancer.

4. Hormonal production will be affected.

5. The testes are at greater risk of torsion.

Correct Answer: 1,2,3,5 Rationale 1: Sperm production by abdominal testes is affected by the heat of the body.

Rationale 2: Positioning of the testes in the scrotum reduces the risk of injury.

Rationale 3: Statistics have shown this statement is correct.

Rationale 4: Production of hormones is not affected by the location of the testes.

Rationale 5: Abdominal testes have a higher risk of twisting on its blood supply.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-3 Question 13 Type: MCSA

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A teenage girl sees the school nurse to ask about a vaginal discharge that she has had for a month. The nurse suspects a sexually transmitted disease. What is the nurse’s next step?

1. Notify the girl’s parents.

2. Determine the girl’s sexual partners.

3. Encourage the girl to go to the free clinic or her private health care provider for an examination and possible treatment.

4. Notify the health department of the sexually transmitted disease.

Correct Answer: 3 Rationale 1: If the nurse notifies the parents without the girls’ permission, the nurse will lose the confidence of the girl and her friends. The nurse will encourage the girl to inform her parents.

Rationale 2: The nurse does not need to determine who the sexual partner(s) might be. The nurse will encourage the girl to inform her partner(s).

Rationale 3: This is an appropriate intervention for a school nurse.

Rationale 4: The nurse has not diagnosed a sexually transmitted disease and is not the person that reports the disease to the health department.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-8 Question 14 Type: MCSA A child with acute renal failure is being treated with peritoneal dialysis. Following medical orders, the dialysate has been infused into the child’s abdomen. When the dialysate is drained, the nurse notes the following findings.

Which finding requires notification of the physician?

1. The dialysate is clear on return.

2. The volume of drained dialysate is less than the volume infused.

3. The child is restless, wanting to get up and play.

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4. The child’s vital signs are basically the same as were noted on infusion.

Correct Answer: 2 Rationale 1: This is a normal finding and does not require reporting.

Rationale 2: This indicates fluids are being retained and is not desirable. The physician should be notified.

Rationale 3: This could indicate the child is feeling better. It is a desired effect and does not require reporting to the physician.

Rationale 4: This is an expected finding. No dramatic differences in vital signs should be noted.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 31-7 Question 15 Type: MCMA A four-year-old girl has been treated for three urinary tract infections (UTI) in the last two years. Which instructions can the nurse give to the mother to help reduce the child’s risk of acquiring another UTI? Standard Text: Select all that apply.

1. Wear only nylon underwear for better air flow.

2. Teach the child to wipe from front to back.

3. Encourage the child to take long baths by allowing the child bubbles and toys in the tub.

4. Encourage the child to drink additional fluids throughout the day.

5. Plan potty breaks every two hours throughout the day.

Correct Answer: 2,4,5 Rationale 1: The child should wear cotton underwear.

Rationale 2: This prevents bacteria from the rectum from being introduced into the urethra.

Rationale 3: Bubble baths should be avoided.

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Rationale 4: Extra fluids will “wash” bacteria out of the bladder.

Rationale 5: Children get so involved in playing that they often hold their urine. Voiding every two hours will reduce the time for bacteria to grow in the bladder.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-2 Question 16 Type: MCSA A baby is born with bladder exstrophy. Immediate care for this infant will include which intervention?

1. Measuring intake and output 2. Inserting a Foley catheter 3. Covering the defect with sterile plastic wrap 4. Palpating the bladder mass to ensure urine is expelled Correct Answer: 3 Rationale 1: Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible.

Rationale 2: The bladder is open to the abdomen. A Foley catheter cannot be inserted.

Rationale 3: This reduces the contamination of the bladder, which should be sterile.

Rationale 4: The bladder is very sensitive and palpation would cause unnecessary pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-3 Question 17 Type: MCSA Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

A child is admitted to the hospital with a diagnosis of “rule out” urinary tract infection. A clean-catch urine specimen is submitted to the lab. When the results return, the nurse evaluates the findings. Which finding would the nurse question?

1. 2+ White blood cells 2. 1+ red blood cells 3. Urine appearance: cloudy 4. Specific gravity: 1009 Correct Answer: 4 Rationale 1: White blood cells are expected.

Rationale 2: Red blood cells are common in the urine of a child with a urinary tract infection.

Rationale 3: With white blood cells in the urine, this is a common finding.

Rationale 4: This is a very dilute urine. With WBCs, RBCs, and bacteria in the urine, you would expect the urine to contain more solutes.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-2

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Ball, Child Health Nursing, 3/E Chapter 32 Question 1 Type: MCSA The home health nurse is visiting a three-month-old who has been diagnosed with congenital hypothyroidism and is taking daily thyroxine. The baby is on soy formula and is at the 50th percentile for height and weight. It is important that the mother understands that: 1. Parents may stop the thyroxine as long as the baby remains in the 50th percentile for height and weight.

2. Soy-based formula can interfere with the absorption of thyroxine.

3. Dairy-based formula is contraindicated when an infant is taking thyroxine.

4. As long as the baby is growing along the same growth curve, no interventions are necessary.

Correct Answer: 2 Rationale 1: To ensure adequate growth and development, the hormone must be taken throughout life.

Rationale 2: Soy-based formula can interfere with the absorption of thyroxine.

Rationale 3: Dairy-based formula does not interfere with thyroxine.

Rationale 4: Frequent checks must be done to assess the baby for inadequate growth.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-2 Question 2 Type: MCMA The nurse is providing information to a teenager newly diagnosed with diabetes and his parents. The nurse teaches them that the signs of diabetic ketoacidosis (DKA) include: Standard Text: Select all that apply.

1. Change in mental status.

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2. Tachycardia.

3. Fruity breath odor.

4. Rapid, shallow respirations.

5. Abdominal pain.

Correct Answer: 1,3,5 Rationale 1: A change in mental state can be associated with DKA. Rationale 2: Tachycardia is not a typical symptom of DKA. Rationale 3: A fruity breath odor is common when the client is in a state of ketoacidosis.

Rationale 4: Respirations are rapid, but deep (Kussmaul's breathing) in DKA. Rationale 5: Abdominal pain is commonly seen with DKA. Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-3 Question 3 Type: MCSA A child weighing 18.2 kg with a history of diabetes insipidus has been admitted to the hospital. Which of the physician's orders would the nurse question?

1. Stat electrolytes 2. Urine specific gravity with each void 3. DDAVP (desmopressin) PO 4. Restrict oral fluids to 500 mL every 24 hours.

Correct Answer: 4 Rationale 1: Stat electrolytes would be an appropriate order to check for hypernatremia.

Rationale 2: Urine specific gravity is checked because it is often low.

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Rationale 3: DDAVP is the drug of choice for a child with DI. Rationale 4: Fluid replacement, not fluid restriction, is necessary for child with DI. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-3 Question 4 Type: MCSA A five-year-old with a history of being treated for hypopituitarism comes to the physician with complaints of right hip and leg pain. The nurse understands that this symptom might be related to which medication that is used to treat hypopituitarism?

1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin acetate) at HS 4. Cortisone injections Correct Answer: 1 Rationale 1: Growth hormone injections and hypopituitarism have been associated with slipped capital femoral epiphysis, which manifests with complaints of hip or knee pain.

Rationale 2: Insulin is not used to treat hypopituitarism.

Rationale 3: DDAVP reduces urinary output. It does not cause slipped capital femoral epiphysis.

Rationale 4: Cortisone is not used for hypopituitarism.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 5 Type: MCSA An adolescent female with untreated Graves' disease is admitted to the hospital. The nurse expects to find which signs and symptoms in this client?

1. Hyperglycemia, ketonuria, and glucosuria 2. Weight gain, hirsutism, and muscle weakness 3. Tachycardia, fatigue, and heat intolerance 4. Dehydration, metabolic acidosis, and hypertension Correct Answer: 3 Rationale 1: Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 2: Weight gain, hirsutism, and muscle weakness are seen in clients with Cushing's disease.

Rationale 3: Clinical manifestations of Graves' disease are tachycardia, fatigue, and heat intolerance, seen with hyperthyroidism.

Rationale 4: Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-5 Question 6 Type: MCSA A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate antidiuretic hormone), a complication of his meningitis. What would the nurse expect to see on this child’s lab results?

1. Hyponatremia 2. Hypocalcemia 3. Hyperglycemia 4. Hypernatremia Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: SIADH is associated with increased permeability in distal renal tubes, leading to water intoxication and low sodium.

Rationale 2: Hypocalcemia is not seen with SIADH. Rationale 3: Hyperglycemia is not related to SIADH. Rationale 4: Hypernatremia is seen with DI, not SIADH. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-5 Question 7 Type: MCSA The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed due to a tumor. The nurse knows that the mother needs more instructions when the mother states: 1. "I will call the doctor if my child has restlessness and confusion."

2. "If my child has any gastric irritation, I will give him antacids."

3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone."

4. "I will give my child his hydrocortisone in the morning."

Correct Answer: 3 Rationale 1: Restlessness and confusion can be signs of adrenal insufficiency, and the physician would need to know these symptoms. No further instruction is needed.

Rationale 2: Hydrocortisone can cause gastric irritation, and antacids are given between meals. No further instruction is needed.

Rationale 3: If the child is ill and can't take hydrocortisone by mouth, the child would need to have an injection.

Failure to give hydrocortisone could lead to severe illness and cardiovascular collapse. The mother needs additional instruction.

Rationale 4: The child should have hydrocortisone in the morning, which mimics the normal diurnal pattern of cortisol secretion. No further instruction is needed.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 32-6 Question 8 Type: MCSA The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which of the physician’s orders should the nurse question?

1. Neurological checks hourly 2. Insert urinary catheter and measure output hourly.

3. NPH insulin IV at 0.1 units/kg per hour 4. Stat serum electrolytes Correct Answer: 3 Rationale 1: Hourly neuro checks are an appropriate order.

Rationale 2: Urinary catheter and hourly outputs are appropriate.

Rationale 3: NPH insulin is never administered IV. A short-acting insulin needs to be ordered.

Rationale 4: Stat electrolytes are an appropriate order.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-8 Question 9 Type: MCSA A teenager has arrived in the emergency department (ED) with confusion. The physician suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 76l5 mg/dL. The nurse expects that this teen has which symptoms?

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1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration Correct Answer: 3 Rationale 1: Tachycardia is seen in hypoglycemia.

Rationale 2: Sweating, photophobia, and tremors are indicative of hypoglycemia.

Rationale 3: Dry mucous membranes, blurred vision, and weakness are seen with hyperglycemia.

Rationale 4: Dry skin and dehydration are signs of hyperglycemia, but shallow breathing is a sign of hypoglycemia.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-7 Question 10 Type: MCSA A 12-year-old has been selected to be a cheerleader for her middle school. This child has been recently diagnosed with type 1 diabetes. In teaching this child's mother about care for her child, the nurse wants the mother to understand that with increased physical activity, the child will need: 1. Decreased food intake.

2. Increased doses of insulin.

3. Increased food intake.

4. Decreased doses of insulin.

Correct Answer: 3 Rationale 1: Decreased food intake would increase the chance of hypoglycemia.

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Rationale 2: Increased dose of insulin would cause hypoglycemia. Exercise causes insulin to be used more efficiently by the body, so an increase in insulin would not be needed.

Rationale 3: An increase in physical activity requires an increase in caloric intake to prevent hypoglycemia.

Rationale 4: A decreased dose of insulin would not allow the sugar to enter the cells where it is needed during exercise.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-8 Question 11 Type: MCSA The nurse is teaching a teenage client newly diagnosed with type 1diabetes about complications of the disease.

The nurse explains that clients with type 1 diabetes can avoid lipoatrophy by: 1. Rotating injection sites.

2. Checking blood sugars at mealtime and bedtime.

3. Using a sliding scale for additional coverage.

4. Administration of insulin via insulin pump.

Correct Answer: 1 Rationale 1: Lipoatrophy is caused by using the same insulin injection site.

Rationale 2: Checking blood sugars does not influence lipoatrophy.

Rationale 3: A sliding scale does not influence lipoatrophy.

Rationale 4: Insulin administration via pump doesn't influence lipoatrophy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 32-8 Question 12 Type: MCMA The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions to minimize pain will the nurse include in the teaching?

Standard Text: Select all that apply.

1. Do not reuse needles.

2. Remove all bubbles from the syringe before injecting.

3. Have the child flex the muscle during injection.

4. Inject insulin when it is cold.

5. Do not change the direction of the needle during insertion or withdrawal.

Correct Answer: 1,2,5 Rationale 1: Reusing needles leads to more pain on injection.

Rationale 2: Removing bubbles from the syringe minimizes pain.

Rationale 3: Flexing or tensing muscles during injection causes more discomfort.

Rationale 4: Insulin should be injected when it is at room temperature to minimize pain.

Rationale 5: Keeping the direction of the syringe constant will minimize pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-8 Question 13 Type: MCSA

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The nurse is caring for a hospitalized three-year-old admitted with a history of syndrome of inappropriate antidiuretic hormone (SIADH). He has just received his breakfast tray. Which food should the nurse remove from his tray?

1. Oatmeal 2. Yogurt 3. Biscuit 4. Cantaloupe Correct Answer: 4 Rationale 1: A child with SAIDH may have carbohydrates and fiber, such as in oatmeal.

Rationale 2: A child with SIADH may have dairy products, such as yogurt.

Rationale 3: A child with SIADH may have carbohydrates, such as in a biscuit.

Rationale 4: A child with SIADH is on a fluid restriction. Cantaloupe contains significant fluid volume, so it would not be a good food for this child to consume.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-3 Question 14 Type: MCSA Mandatory testing in the newborn nursery determines that the infant has hypothyroidism. When discussing the treatment with the new mother, the mother states that she doesn’t believe in taking medications. The nurse would explain that failure to treat the infant with the appropriate medication will result in: 1. Heart disease.

2. Mental retardation.

3. Renal failure.

4. Thyroid storm.

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Correct Answer: 2 Rationale 1: If the hypothyroidism is left untreated, the child will experience bradycardia but will not develop heart disease.

Rationale 2: Untreated hypothyroidism will lead to mental retardation.

Rationale 3: Untreated hypothyroidism does not lead to renal failure.

Rationale 4: Thyroid storm is a complication of hyperthyroidism, not hypothyroidism.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-2 Question 15 Type: MCMA The school nurse has noticed an increase in the number of children in the school being diagnosed with type 2 diabetes. Which changes could the nurse implement at school to help reduce students’ risk for developing type 2 diabetes?

Standard Text: Select all that apply.

1. Increase the amount of daily physical activity.

2. Meet with all parents and explain the risk that is associated with obesity.

3. Test each child’s urine monthly.

4. Teach the parents to avoid administering aspirin to their children.

5. Work with the cafeteria to decrease the amount of fat in the foods served.

Correct Answer: 1,2,5 Rationale 1: Increased physical activity will decrease a child’s risk of developing type 2 diabetes.

Rationale 2: Obese children have an increased risk of type 2 diabetes. Working with the parents, the nurse can reduce the obesity in the school.

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Rationale 3: Testing urine will not decrease the risk of developing type 2 diabetes, although it may lead to earlier diagnosis of the disease.

Rationale 4: Aspirin administration is not related to type 2 diabetes.

Rationale 5: A diet high in fat is associated with type 2 diabetes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-8 Question 16 Type: MCSA The child was diagnosed with phenylketonuria shortly after birth and has been treated by the endocrine clinic for the last four years. The mother has missed the last three appointments. When the child keeps the next appointment, the mother assures the nurse that the child has followed the dietary restrictions. Which finding would make the nurse question this statement?

1. The child’s body has a musty odor.

2. This child is a blue-eyed blond.

3. The child appears sleepy and uninterested in the surroundings.

4. The child has a sunburn over his entire body.

Correct Answer: 1 Rationale 1: The odor is caused by the excretion of phenylketone by-products through the skin and would indicate noncompliance with the dietary restrictions.

Rationale 2: While this is a characteristic of most children with PKU, it is not related to dietary intake or restrictions.

Rationale 3: This is not a symptom of untreated phenylketonuria.

Rationale 4: Photophobia is not associated with PKU. The child with untreated PKU has an eczema rash.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-3 Question 17 Type: MCSA Based on physical findings, including a webbed neck and low hairline, the newborn female infant is suspected of having Turner’s syndrome. The baby is in the newborn nursery while preparations are made for further evaluation including karyotyping. The nurse will want to monitor this baby for common associated conditions including: 1. Club foot (talipes equinovarus).

2. Congenital heart anomalies.

3. Hyperbilirubinemia due to liver abnormalities.

4. Diaphragmatic hernia.

Correct Answer: 2 Rationale 1: Club foot is not associated with Turner’s syndrome.

Rationale 2: Congenital heart anomalies, including coarctation of the aorta, frequently are associated with Turner’s syndrome.

Rationale 3: The girl with Turner’s syndrome has the normal risk for hyperbilirubinemia. It is not associated with Turner’s syndrome.

Rationale 4: Diaphragmatic hernias are not associated with Turner’s syndrome.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-3 Question 18 Type: MCSA A three-year-old child was born with congenital adrenal insufficiency and is being treated with oral hydrocortisone. When the child develops pneumonia and is admitted to the hospital, the nurse would expect the dose of hydrocortisone to be: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Stopped.

2. Reduced by 50%.

3. Continued as previously prescribed.

4. Increased.

Correct Answer: 4 Rationale 1: Hydrocortisone is the glucocorticoid that helps the body deal with stress. It would be inappropriate to stop the medication.

Rationale 2: The drug dosage would not be decreased.

Rationale 3: During periods of stress, the child will need additional corticosteroids.

Rationale 4: During periods of stress including illness and surgery, the dose of steroids needs to be increased.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-6 Question 19 Type: MCSA During the hospital stay in the newborn nursery, the infant is tested for galactosemia. When the test is positive, the parents are educated about treatment for galactosemia. The infant will be placed on what type of infant feeding?

1. Goat’s milk formula 2. Breast milk 3. Cow’s milk-based formula 4. Meat-based formula such as Nutramigen Correct Answer: 4 Rationale 1: Goat’s milk formula contains galactose and is excluded from the infant’s diet.

Rationale 2: Breast milk contains galactose and is excluded from the infant’s diet.

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Rationale 3: Cow’s milk-based formula contains galactose and is excluded from the infant’s diet.

Rationale 4: The meat-based formula does not contain galactose and is appropriate for the infant’s diet.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-9 Question 20 Type: MCSA When the newborn female is born with ambiguous genitalia, the follow-up investigation discovers adrenogenital syndrome (also called congenital adrenal hyperplasia). The parents question why the baby’s genitalia looks more male than female. The nurse would explain that: 1. The disorder caused the infant to be a hermaphrodite with both male and female sex organs.

2. The changes in the genitalia are due to increased androgens secondary to deficient cortisol.

3. The excessive cortisol caused the enlargement of the female tissue, creating a male appearance.

4. The child has only one sex chromosome resulting in an XO configuration.

Correct Answer: 2 Rationale 1: This statement is incorrect. The child’s internal organs will be ovaries only.

Rationale 2: Deficient cortisol causes the amount of ACTH to be high, over stimulating the adrenal production of androgens which causes the pseudo-masculinization.

Rationale 3: The cortisol level is decreased, not increased.

Rationale 4: XO sex chromosomes describe Turner’s syndrome, not CAH. Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-9 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Chapter 33 Question 1 Type: MCSA The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal?

1. The posterior fontanel is open.

2. The infant has good head control when held upright.

3. The infant is able to roll only from abdomen to back.

4. The anterior fontanel is open and soft.

Correct Answer: 1 Rationale 1: The posterior fontanel closes between two and three months of age.

Rationale 2: Good head control is expected at four months of age.

Rationale 3: Rolling from abdomen to back is a skill the four-month-old should be learning.

Rationale 4: An open anterior fontanel, which is soft, is a normal finding at four months.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-1 Question 2 Type: MCSA The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician’s order would the nurse question?

1. Passive range-of-motion exercises 2. Oxygen at 2L nasal cannula to keep saturation above 95% Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Hourly vital signs and neuro checks 4. Elevate head of bed 30 degrees Correct Answer: 1 Rationale 1: Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible.

Rationale 2: Oxygen should be ordered to keep the child's O2 saturation above 95%.

Rationale 3: Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition.

Rationale 4: The head is elevated 30 degrees to help decrease increased intracranial pressure.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-2 Question 3 Type: MCSA A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include: 1. Appendicitis.

2. Bowel obstruction.

3. Urinary tract infection.

4. Kidney stones.

Correct Answer: 4 Rationale 1: Appendicitis does not occur as a result of the ketogenic diet.

Rationale 2: The ketogenic diet does not cause a bowel obstruction.

Rationale 3: Urinary tract infections are not a result of a ketogenic diet.

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Rationale 4: Kidney stones are seen in 5% of children on a ketogenic diet.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-3 Question 4 Type: MCSA A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse’s initial action?

1. Take vital signs.

2. Establish an intravenous line.

3. Perform rapid neurological assessment.

4. Maintain patent airway.

Correct Answer: 4 Rationale 1: Taking vital signs is important, but airway always comes first.

Rationale 2: Once the airway is secure, securing an IV is vital.

Rationale 3: A rapid neurological assessment is appropriate once the airway is secure.

Rationale 4: Airway is always the priority of care.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-3 Question 5 Type: MCSA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child has been put on valproic acid (Depakote) for control of seizures. The nurse knows that the mother does not understand the effects of valproic acid when she states: 1. "I will not use carbonated beverages to dilute his medication."

2. "I will give his medicine on an empty stomach so he will absorb it better."

3. "I will not let him chew his tablet."

4. "I will bring him to the physician office for regular blood work to check bleeding times."

Correct Answer: 2 Rationale 1: Carbonated beverages should never be used to dilute valproic acid.

Rationale 2: Valproic acid (Depakote) should be given with foods to decrease GI irritation.

Rationale 3: This child should not be allowed to chew a valproic acid tablet.

Rationale 4: It is appropriate to have periodic blood studies to check bleeding times and platelet count.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 33-3 Question 6 Type: MCSA A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show: 1. Decreased protein count.

2. Clear, straw-colored fluid.

3. Positive for RBCs. 4. Decreased glucose level.

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Bacterial meningitis causes CSF protein levels to be elevated due to swelling and obstruction of CSF flow.

Rationale 2: In bacterial meningitis, the fluid is often cloudy with WBCs. Rationale 3: The nurse would expect WBCs to be elevated due to the infection. The RBCs may indicate a bloody tap.

Rationale 4: Glucose levels are low in CSF when a child has bacterial meningitis.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-4 Question 7 Type: MCSA The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis?

1. Impaired gas exchange 2. Infection, risk for 3. Anxiety (parental) 4. Acute pain Correct Answer: 1 Rationale 1: Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange.

Rationale 2: The child already has an infection.

Rationale 3: The parents will be anxious about the outcome for their child, but this is not the priority diagnosis.

Rationale 4: Pain management is important but not the priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 33-4 Question 8 Type: MCSA The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question?

1. Vital signs and neuro checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference Correct Answer: 3 Rationale 1: Frequent vital signs and neuro checks are needed postoperatively.

Rationale 2: Small, frequent feedings are appropriate to decrease the chance of vomiting.

Rationale 3: The nine-month-old should be placed in a flat position so that CSF drainage is not too rapid.

Rationale 4: Daily head circumferences are needed to help evaluate shunt functioning.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-5 Question 9 Type: MCSA A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes: 1. Applying a diaper to prevent contamination of sac.

2. Positioning the newborn in a side-lying position.

3. Encouraging the mother to hold the newborn, because she will not be able to pick him up after surgery.

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4. Positioning the newborn in a prone position.

Correct Answer: 4 Rationale 1: A diaper is not used because it also puts pressure on the sac.

Rationale 2: A side-lying position would be contraindicated because it would place pressure on the sac.

Rationale 3: The mother should not hold the baby because that would put too much pressure on the sac.

Rationale 4: The newborn should be placed in a prone position to keep pressure off the sac.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-5 Question 10 Type: MCMA In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to: Standard Text: Select all that apply.

1. Expect the child to have normal intelligence.

2. Use latex precautions.

3. Allow the child to do her own self-catheterization.

4. Ensure that the child has a low-fiber diet.

5. Encourage the child to shift positions hourly when in her wheelchair.

Correct Answer: 1,2,3,5 Rationale 1: Many children with myelodysplasia have normal intellect. They should be treated according to their intellectual level rather than their motor development.

Rationale 2: Children with myelodysplasia are at great risk for latex allergy. It is important to use latex-free products.

Rationale 3: Self-catheterization fosters independence in this child. It is important to maintain the same schedule as much as possible when this child is hospitalized.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function.

Rationale 5: Due to decreased sensation in the buttocks and lower extremities, it is very important for the child to shift positions while she is in her wheelchair to prevent pressure sores.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-5 Question 11 Type: MCSA The nurse is teaching the kindergarten teacher about a five-year-old with cerebral palsy who will be starting school. The child has a continuous baclofen pump. The nurse informs the teacher of possible side effects of this drug, including: 1. Diarrhea.

2. Hypertonia.

3. Hypotonia.

4. Restlessness.

Correct Answer: 3 Rationale 1: Continuous baclofen infusion does not cause diarrhea.

Rationale 2: Hypertonia is not seen as a side effect of baclofen infusion.

Rationale 3: Hypotonia is possible if the child is getting too much baclofen.

Rationale 4: Restlessness is not seen with baclofen; rather, these children can be drowsy and sleepy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 12 Type: MCSA A nine-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?

1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia Correct Answer: 1 Rationale 1: Hypotonia in infancy and muscle instability are seen in ataxic cerebral palsy.

Rationale 2: Hypertonia and persistent primitive reflexes are seen in spastic CP. Rationale 3: Tremors and exaggerated posturing are seen in dyskinetic cerebral palsy.

Rationale 4: Hemiplegia and hypertonia are seen in spastic cerebral palsy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-6 Question 13 Type: MCSA A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: 1. A sign that this child has a spinal cord injury.

2. A sign of increased intracranial pressure.

3. Typical for a sleeping child at this age.

4. A sign that the child’s condition is improving.

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Correct Answer: 2 Rationale 1: These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive.

Rationale 2: These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure.

Rationale 3: Normal sleeping pulse at this age is 60-90 bpm.

Rationale 4: Without previous vital signs, there is no way to determine the changes in the vital signs.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 33-7 Question 14 Type: MCSA A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for: 1. Periorbital ecchymosis.

2. Subdural hematoma.

3. Protruding bone.

4. Epidural hematoma.

Correct Answer: 1 Rationale 1: Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture.

Rationale 2: Subdural hematoma might be seen with a linear fracture.

Rationale 3: Protruding bone might be seen with a compound fracture.

Rationale 4: Epidural hematoma is seen with linear fracture.

Global Rationale: Cognitive Level: Applying Client Need: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-7 Question 15 Type: MCSA The teacher is speaking to the school nurse about one of the girls in the fifth grade. The girl has always been a good student but lately seems to be daydreaming a lot. The teacher says, “Sometimes when I ask her a question, she will just stare at me for 15 seconds, then blink and ask me to repeat the question. What do you think is going on with her?” Based on this data, the nurse will suspect: 1. The girl has a crush on a boy in the class.

2. The girl has increased intracranial pressure.

3. The child may have had a head injury.

4. The girl is experiencing absence seizures.

Correct Answer: 4 Rationale 1: There is no data to suspect a childhood crush is creating the situation.

Rationale 2: There is no indication of increased intracranial pressure.

Rationale 3: There is no indication of a head injury.

Rationale 4: Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-3 Question 16 Type: MCSA Following an outbreak of chicken pox in the school, the school nurse is concerned that children are at risk for Reye syndrome. The nurse sends home letters reminding the parents not to administer aspirin and describes the initial symptoms of Reye syndrome which are: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Nausea, vomiting, and confusion.

2. Headache, vomiting, and seizures.

3. Sore throat, moist respirations, and cough.

4. Fever, rash, and photophobia.

Correct Answer: 1 Rationale 1: These are the early symptoms of Reye syndrome.

Rationale 2: These symptoms are associated with a malfunctioning shunt and not the early symptoms of Reye syndrome.

Rationale 3: These symptoms are more likely to indicate pneumonia, not Reye syndrome.

Rationale 4: These are not the early symptoms of Reye syndrome.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-2 Question 17 Type: MCMA The mother brings her five-month-old infant to the clinic for a well-child visit. The mother tells the nurse that the baby’s father had febrile seizures when he was an infant. The mother says she is concerned her baby will have a febrile seizure and wants to know what she should do to prevent it. The nurse explains: Standard Text: Select all that apply.

1. That the baby has no more risk of febrile seizures than any other baby.

2. When the infant has a fever, the mother should give the baby dose-appropriate aspirin.

3. That the baby should be sponged with cold water.

4. The mother should increase the child’s fluid intake.

5. That after the tepid bath, the child should be patted dry.

Correct Answer: 4,5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Febrile seizures run in families and are more common in males.

Rationale 2: Aspirin should be avoided due to the risk for Reye syndrome.

Rationale 3: Cold water may cause shivering, which will increase the body temperature.

Rationale 4: Fluid intake will help heat loss.

Rationale 5: A tepid bath will bring down the temperature; patting, instead of rubbing, will help keep the child’s temperature down.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-3 Question 18 Type: MCMA The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newborn indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction. The nurse will monitor the infant for signs of neonatal abstinence syndrome, including: Standard Text: Select all that apply.

1. Poor feeding.

2. Difficult to arouse.

3. Constipation.

4. Seizures.

5. Yawning.

Correct Answer: 1,4,5 Rationale 1: This is a symptom of neonatal abstinence syndrome.

Rationale 2: These infants are usually restless and irritable, not sleepy.

Rationale 3: The infant is more likely to have diarrhea.

Rationale 4: Seizures are common in the child with neonatal abstinence syndrome.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 5: The infant with neonatal abstinence syndrome yawns frequently.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-2 Question 19 Type: MCSA When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother?

1. The mother leaves the filled mop bucket on the floor while in another room.

2. The mother turns all pan handles to the back of the stove.

3. The mother fills the bath tub before bringing the baby into the bathroom.

4. When riding in a car, the child is in a car seat in the middle of the back seat.

Correct Answer: 1 Rationale 1: Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in head first. Because of mobility limitations, the child may not be able to get out of the bucket without help.

Rationale 2: This is appropriate to reduce the risk of injury.

Rationale 3: This allows the mother to adjust the temperature of the bath water and reduces the risk of burns.

Rationale 4: This is the safest place for the child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-9

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Ball, Child Health Nursing, 3/E Chapter 34 Question 1 Type: MCMA The nurse is assessing a four-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation?

Standard Text: Select all that apply.

1. Fails to make eye contact 2. Flinches when touched on the arm 3. History of limited prenatal care and precipitant delivery 4. Head circumference has not changed in over one year 5. Flat facial expressions Correct Answer: 1,2,3,5 Rationale 1: Making eye contact with the nurse and caregiver is part of the child's overall affect and social skills.

A child who fails to make eye contact may have an alteration in mental health.

Rationale 2: Flinching may indicate a desire to avoid contact; this can indicate a mental health issue and should be further evaluated.

Rationale 3: History of prenatal care and delivery can help determine potential alterations in mental health in a child.

Rationale 4: Head circumference is not measured in a four-year-old.

Rationale 5: Affect can be determined by facial expression and response to the nurse, helping to determine mental health.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-1 Question 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA The mother of a six-year-old brings her son to the physician because his teacher thinks he might have attention deficit/hyperactivity disorder (ADHD). The nurse is interviewing the mother about the child's history. The nurse knows that which factors could be associated with ADHD? 1. Measles, mumps, and rubella vaccine 2. Advanced parental age 3. Prenatal exposure to smoke 4. Immune response Correct Answer: 3 Rationale 1: Measles, mumps, and rubella vaccine has been thought to be associated with autism spectrum disorder, though a relationship has never been established through research.

Rationale 2: Advanced parental age has been associated with autism spectrum disorders.

Rationale 3: Research shows that a mother's use of cigarettes during pregnancy can increase the risk for ADHD. Rationale 4: Immune response can be associated with autism spectrum disorders.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Question 3 Type: MCMA The nurse at a high school is screening students for mental health issues. The nurse would want to refer the adolescent for depression if the child shows which symptoms of depression?

Standard Text: Select all that apply.

1. Agoraphobia 2. Somatic complaints 3. Focus on violence Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. Poor self-care 5. Poor school performance Correct Answer: 3,4,5 Rationale 1: Agoraphobia, which is a fear of being in places or situations from which escape might be difficult or embarrassing, is seen in children with a panic disorder, not with depression.

Rationale 2: Somatic complaints are more commonly associated with depression in the younger school-age child.

Rationale 3: Focus on violence can be associated with depression in the adolescent.

Rationale 4: Poor self-care can be associated with depression in an adolescent.

Rationale 5: Poor school performance is associated with depression in the adolescent with depression.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Question 4 Type: MCSA The nurse knows that the mother of a six-year-old needs more teaching about her son's diagnosis of ADHD when she states: 1. "I will develop a reward system for desired behaviors.”

2. "I will take my child to the physician every three months for a weight and height check."

3. "I will let him do his homework while he is watching his favorite television show."

4. "I will stick to the same routine each day after school."

Correct Answer: 3 Rationale 1: A reward system is a part of behavior modification and is appropriate to help the child behave appropriately.

Rationale 2: Children with ADHD should be screened regularly for height and weight to monitor growth, which can be affected by medication.

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Rationale 3: This child should do homework in a quiet environment, away from distractions.

Rationale 4: Maintaining the same daily routine helps the child know expectations, and a nighttime routine helps counteract insomnia.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 34-3 Question 5 Type: MCSA A child with autism is being admitted to the hospital with dehydration. Upon admission, the nurse should: 1. Encourage the parents to avoid bringing favorite toys from home that might be lost.

2. Take the child on a tour of the pediatric unit.

3. Assign the child to his single-bed hospital room.

4. Take the child to the playroom for arts and crafts.

Correct Answer: 3 Rationale 1: Children with autism often carry a special toy. This should be kept with the child.

Rationale 2: Taking a child with autism on a tour of the pediatric unit would be too much stimulation for this child. A quiet, controlled environment is best for a child with autism.

Rationale 3: A single room is the best place for an autistic child if the child must be hospitalized.

Rationale 4: Arts and crafts might be appropriate for an autistic child if they are done in the child's room. Going to the playroom would be too much stimulation for this child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-4

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Question 6 Type: MCSA A nine-year-old has been diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. The nurse teaches parents that this disorder is called: 1. Dysgraphia.

2. Dyscalculia.

3. Dyspraxia.

4. Dyslexia.

Correct Answer: 3 Rationale 1: Children with dysgraphia have difficulty with writing, spelling, and composition.

Rationale 2: Children with dyscalculia have problems with mathematics and computation problems.

Rationale 3: Children with dyspraxia have problems with manual dexterity and coordination.

Rationale 4: Children with dyslexia have difficulty with writing, reading, and spelling.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-5 Question 7 Type: MCSA The nurse is assessing a child with Down syndrome. The child is at greater risk of developing which illness than children who do not have Down syndrome?

1. Rheumatic heart disease 2. Glomerulonephritis 3. Leukemia 4. Hepatitis Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: Heart defects might be seen with Down syndrome, but not rheumatic heart disease, which is associated with Group A beta-hemolytic streptococcus infection.

Rationale 2: Glomerulonephritis is not seen in association with Down syndrome.

Rationale 3: Children with Down syndrome have a significantly higher than average risk of developing leukemia.

Rationale 4: Hepatitis is not associated with Down syndrome.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 8 Type: MCMA A nurse is performing a developmental assessment on several children in a clinic setting. Which children exhibit a delay in meeting developmental milestones?

Standard Text: Select all that apply.

1. An 18-month-old toddler who is unable to speak in sentences 2. A two-year-old who is unable to cut with scissors 3. A two-year-old who cannot recite her phone number 4. A six-year-old who is unable to sit still for a short story 5. A five-year-old who is unable to button his shirt Correct Answer: 4,5 Rationale 1: An 18-month-old is not usually able to speak in sentences. This is a skill to be accomplished by the age of two-and-a-half years.

Rationale 2: A child who cannot cut with scissors by kindergarten age is considered abnormal.

Rationale 3: A two-year-old is not expected to be able to recite a phone number.

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Rationale 4: A six-year-old should be able to sit still for a short story. A three- to five-year-old should be able to sit still through a short story.

Rationale 5: A five-year-old should be able to button his shirt.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 9 Type: MCMA A seven-year-old girl has been clinging to her mother and refusing to go to school. The child is diagnosed with separation anxiety disorder, and the treatment plan will include cognitive-behavioral therapy (CBT). The nurse would explain to the parents that CBT will include: Standard Text: Select all that apply.

1. Self-talking.

2. Relaxation.

3. Hypnosis.

4. Anti-depressant medications.

5. Recognition of feelings.

Correct Answer: 1,2,5 Rationale 1: Self-talking helps a child to focus the inner thoughts on the desired behavior.

Rationale 2: Teaching self-relaxation skills can help the child to reduce anxiety.

Rationale 3: Hypnosis is not a component of cognitive-behavioral therapy.

Rationale 4: Although medications may be a part of the treatment plan, it is not a component of cognitivebehavioral therapy.

Rationale 5: Recognition and acceptance of feelings helps the child to move forward toward a desired behavior.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34-4 Question 10 Type: MCSA The nurse is working with the mother of a child with autism. The goal of the session is to plan strategies to increase the child’s socialization. The nurse is explaining behavior modification as a treatment process. The nurse will encourage the mother to: 1. Create a reward system when the child interacts with a person.

2. Punish the child when the child’s social behaviors are inappropriate.

3. Use dolls to demonstrate appropriate social interactions to the child.

4. Enroll the child in a day care to encourage interaction with other children.

Correct Answer: 1 Rationale 1: This is appropriate treatment involving behavior modification.

Rationale 2: Behavior modification uses positive, not negative, reinforcement to encourage the desired behavior.

Rationale 3: This activity would be a component of play therapy.

Rationale 4: Enrolling the child in a day care may help with interactions, but this is not a description of behavior modification.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-7 Question 11 Type: MCSA The waiting room of the mental health clinic is full of children with various mental health issues. The nurse watches the children and notes that which child is displaying symptoms of autism?

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1. Four-year-old girl who doesn’t make eye contact with mother and resists the mother’s touch 2. Three-year-old boy who joins one group of children then moves to another group of children without joining their activities 3. 18-month-old child who walks around the area using the furniture to provide balance 4. Six-year-old boy who chatters constantly to anyone who will listen Correct Answer: 1 Rationale 1: Although boys are affected more often than girls, lack of eye contact and resistance to physical touch are common symptoms of autism.

Rationale 2: Although this child is not interacting with other children, it is obvious that the child is aware of other children and interested in their activities, actions that are not indicative of autism.

Rationale 3: This child may be developmentally delayed, as this behavior is typical of a 10- to 12-month-old child.

Rationale 4: Children with autism often have language delays and impairment. This child does not have any obvious language issues.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 12 Type: MCMA The school nurse and teacher are working on a plan to improve the behavior and learning of a child recently diagnosed with attention deficit/hyperactivity disorder (ADHD). Which activities will the nurse suggest be included in the plan?

Standard Text: Select all that apply.

1. Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child 2. Placing the child’s desk at the back of the room to reduce distractions 3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

5. Determining areas where the child performs well and using these areas to promote self-esteem Correct Answer: 3,4,5 Rationale 1: It is not the nurse’s or teacher’s place to suggest medications for this child.

Rationale 2: The child’s desk should be placed at the front of the room to promote attention.

Rationale 3: Consistency is important for the child with ADD/ADHD and reduces impulsive behavior.

Rationale 4: Decorations are distracting and should be limited.

Rationale 5: This is appropriate and will help reduce “acting out” behaviors.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-6 Question 13 Type: MCSA A mother brings her 11-year-old son to the pediatric clinic for investigation of stomach complaints. The mother says that for the last two months, the child has complained of abdominal pain three to four mornings per week.

The mother states the child usually complains on school days and always seems to be better by afternoon. The child was able to attend a weekend Boy Scout camp without difficulty but has missed several days of school due to complaints. The nurse would suspect which mental health disorder?

1. Separation anxiety 2. Depression 3. School phobia 4. Bipolar disorder Correct Answer: 3 Rationale 1: Separation anxiety is most common in girls between the ages of seven and nine and may be accompanied by depression when separated. The child was able to successfully separate for a non-school activity.

Rationale 2: Depression is often manifested by sleep issues, avoidance of social interactions, and low energy.

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Rationale 3: The child is using somatic complaints to avoid attending school.

Rationale 4: Bipolar disorder involves periods of hyperactivity alternating with periods of lethargy.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Question 14 Type: MCSA The school nurse notices a sixth-grade girl with bald patches in her hair. The hair itself is clean and shiny. Prior to referring the girl to her healthcare provider for alopecia, the nurse would want to watch the child for signs of: 1. Lice.

2. Dietary imbalances.

3. Schizophrenia.

4. Trichotillomania.

Correct Answer: 4 Rationale 1: Lice cause attachments of nits to the hair shaft, not hair loss.

Rationale 2: The nurse can assess height, weight, and BMI but will not be able to determine if dietary imbalances is the cause of the problem.

Rationale 3: Schizophrenia is a psychotic disorder whose symptoms include flat affect, loose associations, delusions, and hallucinations.

Rationale 4: Trichotillomania is the term for a condition where children pull out their hair during periods of stress.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 15 Type: MCSA A mother brings her 22-month-old child to the well-child clinic for an evaluation. The mother states that this child does not seem to be developing like her sister’s child of the same age. The nurse will perform which screening test that may provide information about the child’s development?

1. MRI of the head 2. An EEG 3. A Denver II 4. Chromosomal study Correct Answer: 3 Rationale 1: The MRI is a diagnostic test, not a screening test, and it is not performed by the nurse.

Rationale 2: An electroencephalogram evaluates brains wave activity of the brain. It does not evaluate the child’s behavior.

Rationale 3: The Denver Developmental Screening Test II is a tool used by the nurse that evaluates language and development.

Rationale 4: A chromosomal test is not a screening test but a diagnostic test. It is not performed to determine developmental delay.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-6

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Ball, Child Health Nursing, 3/E Chapter 35 Question 1 Type: MCSA The nurse in the newborn nursery is doing the admission assessment on a neonate. Which assessment finding would lead the nurse to suspect unilateral congenital hip dysplasia?

1. Lordosis 2. Trendelenburg sign 3. Asymmetry of the gluteal and thigh fat folds 4. Telescoping of the affected limb Correct Answer: 3 Rationale 1: Lordosis does not occur with hip dysplasia.

Rationale 2: Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia.

Rationale 3: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds.

Rationale 4: Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-1 Question 2 Type: MCMA A school health nurse is screening for scoliosis. For what assessment findings would the nurse look?

Standard Text: Select all that apply.

1. Lordosis Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Prominent scapula 3. Pain 4. A one-sided rib hump 5. Uneven shoulders and hips Correct Answer: 2,4,5 Rationale 1: Lordosis is not present with scoliosis.

Rationale 2: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

Rationale 3: Pain generally is not present with scoliosis unless it is severe.

Rationale 4: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

Rationale 5: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-1 Question 3 Type: MCSA The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse knows that parents need further teaching when they state: 1. "We're getting a special car seat to accommodate the casts."

2. "We'll watch for any swelling of the feet while the casts are on."

3. "We'll keep the casts dry."

4. "We're happy this is the only cast our baby will need."

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Using a car seat is the law. Special car seats to accommodate the casts are available and should be utilized.

Rationale 2: Parents should be watching for swelling while the casts are on.

Rationale 3: Keeping the casts dry is important to prevent complications Rationale 4: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks until the corrected foot position is achieved.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35-2 Question 4 Type: MCSA A child must wear a brace for correction of scoliosis. Which nursing diagnosis takes priority at this time?

1. Impaired gas exchange, risk for 2. Altered growth and development, risk for 3. Impaired skin integrity, risk for 4. Impaired mobility, risk for Correct Answer: 3 Rationale 1: Risk for impaired gas exchange is a late effect of scoliosis and would not be the priority. If the patient is compliant with wearing the brace, the risk should be minimized.

Rationale 2: The diagnosis of altered growth and development would not be the priority and should be corrected by the wearing of the brace.

Rationale 3: The skin should be monitored for breakdown in any area where the brace might rub against the skin.

Rationale 4: The diagnosis of impaired mobility would not be the priority and should be corrected if the patient is compliant with wearing the brace.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 35-2 Question 5 Type: MCSA An adolescent has just returned from surgery after spinal fusion surgery. Which assessment finding would take priority at this time?

1. Sleeps when not bothered but arouses easily with stimuli 2. Impaired color, sensitivity, and movement to lower extremities 3. Nausea 4. Pain Correct Answer: 2 Rationale 1: This is a normal response postanesthesia.

Rationale 2: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities.

Rationale 3: Nausea in the postoperative period is not uncommon, but it is not the priority at this time.

Rationale 4: Pain is a common finding in the postoperative period and should be addressed, but impaired color, sensitivity, and movement of the lower extremities is the priority at this time.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-4 Question 6 Type: MCSA The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calvé-Perthes disease.

The nurse knows further teaching is needed about the condition if the family states: 1. "We're glad this will only take about six weeks to correct."

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2. "We understand abduction of the affected leg is important."

3. "We know to watch for areas on the skin that the brace might rub."

4. "We understand swimming is a good sport for Legg-Calvé-Perthes."

Correct Answer: 1 Rationale 1: The treatment for Legg-Calvé-Perthes disease takes approximately two years.

Rationale 2: The leg should be kept in the abducted position to prevent damage to the head of the femur due to Legg-Calvé-Perthes disease.

Rationale 3: A brace is a component of the treatment of Legg-Calve-Perthes disease and is worn to prevent damage to the head of the femur, so skin irritation should be monitored.

Rationale 4: Swimming is a good activity to increase mobility in a child with Legg-Calvé-Perthes disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35-4 Question 7 Type: MCSA Which of the following would take priority when teaching the family how to care for an infant with osteogenesis imperfecta?

1. Teaching the family how to care for an infant in a cast 2. Teaching the family that the trunk and extremities should always be supported when moving this infant 3. Teaching the family how to care for an infant postop spinal surgery 4. Teaching the family how to care for an infant in traction Correct Answer: 2 Rationale 1: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

Rationale 2: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved.

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Rationale 3: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

Rationale 4: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-4 Question 8 Type: MCSA An infant has just returned from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. What should the nurse do first?

1. Apply a warm, moist pack to the feet.

2. Elevate the infant’s legs on pillows.

3. Encourage movement of the toes.

4. Call the physician to report the edema.

Correct Answer: 2 Rationale 1: Warm, moist heat will increase swelling and the moisture may cause the cast to disintegrate.

Rationale 2: The infant’s legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. This is the priority action.

Rationale 3: An infant would not be able to follow directions to move the toes, and in this case it would not be as effective as would elevating the legs on pillows.

Rationale 4: Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement to the toes remained normal.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 35-5 Question 9 Type: MCSA The nurse is teaching a family how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which instruction is appropriate for the nurse to include in parental education in relation to the Pavlik harness?

1. Apply lotion or powder to minimize skin irritation.

2. Check at least two or three times a day for red areas under the straps.

3. Put clothing over the harness for maximum effectiveness of the device.

4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper.

Correct Answer: 2 Rationale 1: Lotion or powder can contribute to skin breakdown and should not be used.

Rationale 2: The skin underneath the straps of the brace should be checked two or three times a day for red areas, which might indicate skin breakdown.

Rationale 3: A light layer of clothing should be worn under the brace to assist in preventing skin breakdown, not over the brace.

Rationale 4: The diaper should be placed under the brace, along with a light layer of clothing.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-5 Question 10 Type: MCSA A child has experienced a sprain of the right ankle. The school nurse should: 1. Leave the ankle open to the air and avoid compressing the area to allow tissue swelling as necessary.

2. Perform passive range-of-motion to the extremity.

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3. Lower the extremity below the level of the heart.

4. Apply ice to the extremity.

Correct Answer: 4 Rationale 1: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should apply a compression bandage to the extremity.

Rationale 2: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should rest the extremity rather than perform range-of-motion.

Rationale 3: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should elevate the extremity.

Rationale 4: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should apply ice to the extremity.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-5 Question 11 Type: MCMA A nurse is assessing a child after an open reduction of a fractured femur. Which signs indicate that compartment syndrome could be occurring?

Standard Text: Select all that apply.

1. Pink, warm extremity 2. Dorsalis pedis pulse present 3. Prolonged capillary refill time 4. Pain not relieved by pain medication 5. Paresthesia of the leg Correct Answer: 3,4,5 Rationale 1: Pink, warm extremity is a normal finding post-fracture reduction.

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Rationale 2: A present dorsalis pedis pulse would be a normal finding post-fracture reduction.

Rationale 3: A prolonged capillary refill time is a sign of compartment syndrome.

Rationale 4: A prolonged capillary refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome.

Rationale 5: Paresthesia is tingling and numbness of the affected extremity and is a sign of compartment syndrome.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-6 Question 12 Type: MCSA A six-year-old boy is admitted to the hospital with a diagnosis of osteomyelitis of the left femur. The plan of care includes a two-week round of intravenous antibiotics. The father questions why the child must be hospitalized and why the child cannot receive oral antibiotics. The nurse explains: 1. The antibiotic of choice is not available in oral form.

2. Blood flow to bones is limited, and parenteral administration is necessary to get appropriate blood levels.

3. Because the child is older now, it is harder to get the child to cooperate with oral antibiotics.

4. Because two weeks of therapy is necessary, the intravenous route will produce fewer side effects.

Correct Answer: 2 Rationale 1: Most antibiotics are available in multiple forms.

Rationale 2: This is accurate information.

Rationale 3: The older child can understand the reason for antibiotics and cooperate.

Rationale 4: Both oral and intravenous antibiotics may have side effects.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-3 Question 13 Type: MCSA A two-year-old child is placed in balanced Bryant’s traction for a fractured right femur. Which finding by the nurse should be reported to the surgeon?

1. The child keeps trying to turn and lay on his belly.

2. The ropes are unequal in length.

3. The child’s buttocks are resting on the bed.

4. The ace bandage wrapping the legs is wrinkled.

Correct Answer: 3 Rationale 1: This child needs a jacket restraint to maintain appropriate positioning if someone cannot stay with him. It does not require notifying the surgeon.

Rationale 2: In balanced traction, the ropes and pulleys determine the traction and the length of the rope is unimportant.

Rationale 3: In order to provide adequate counter-traction, the buttocks should be slightly elevated off the bed.

The surgeon should be notified.

Rationale 4: This is not a significant finding.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35-5 Question 14 Type: MCMA When assigned to the patient on complete bed rest for spinal fusion secondary to scoliosis, the nurse will want to intervene to prevent common complications of immobility. Nursing interventions will include: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Standard Text: Select all that apply.

1. Encouraging use of the spirometer every two hours while the child is awake.

2. Log-rolling the patient every two hours while awake.

3. Increasing intake of milk to maintain bone calcium.

4. Increasing fruit and grains in the diet.

5. Limiting fluid intake to reduce the need to void.

Correct Answer: 1,2,4 Rationale 1: Respiratory complications are a common complication of immobility.

Rationale 2: Turning the patient frequently will reduce pressure on bony prominences.

Rationale 3: Calcium will be pulled from the bones due to immobility. Adding additional calcium in the form of milk will increase the risk of kidney stones.

Rationale 4: Fruit and grains will provide extra fiber to reduce the risk of complication.

Rationale 5: Fluid intake should be increased to “flush” the kidneys.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-5 Question 15 Type: MCSA While at recess, a child falls and hurts his arm. The school nurse is called and suspects a fractured arm. The nurse will apply a splint before transporting the child to the hospital. The nurse will ensure that: 1. The splint is applied firmly enough to prevent swelling.

2. The arm is fully extended in the splint.

3. The splint is fully padded to prevent skin damage.

4. The joints above and below the suspected fracture are immobilized.

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Correct Answer: 4 Rationale 1: The purpose of the splint is not to prevent swelling.

Rationale 2: The nurse will not want to manipulate the arm, so the nurse will splint the arm in the position it is found.

Rationale 3: The splint does not need to be padded.

Rationale 4: This is the important concept in splinting—immobilizing the joint above and below the fracture to prevent movement of the bones.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-6 Question 16 Type: MCSA An 18-month-old child is admitted to the hospital unit for weakness of the lower extremities. Duchenne muscular dystrophy is suspected. Which assessment finding on the admission history and physical is indicative of this disorder?

1. Infant was post-mature by almost two weeks.

2. The child seems very muscular.

3. The child walked early and without support at 10 months.

4. The child’s older sister developed scoliosis in the fourth grade.

Correct Answer: 2 Rationale 1: Post-maturity is not related to Duchenne muscular dystrophy.

Rationale 2: Duchenne muscular dystrophy is also called pseudohypertrophic due to the enlarged appearance of the muscle. The pathophysiology is infiltration of the muscle fibers with fatty tissue.

Rationale 3: This finding is not indicative of Duchenne muscular dystrophy.

Rationale 4: The older sister’s scoliosis is not related to MD. Duchenne MD is sex-linked recessive and affects only boys.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-3 Question 17 Type: MCMA An infant returns to the unit following casting of the leg for talipes equinovarus. Standing orders include monitoring the neurovascular status. In addition to color, for what will the nurse monitor the infant’s foot?

Standard Text: Select all that apply.

1. Warmth 2. Capillary refill 3. Pedal pulse 4. Sensation 5. Movement of the toes Correct Answer: 1,2,4,5 Rationale 1: The temperature of the foot of the casted leg should be compared to the temperature of the other foot.

Rationale 2: This indicates blood return to the tissues and is an important finding.

Rationale 3: The pedal pulse cannot be reached in the casted foot.

Rationale 4: Nerve function is evaluated by touching the toes and noting the child’s response.

Rationale 5: The child is encouraged to wiggle the toes. If the patient is an infant, tickling will cause the child to respond with movement.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Chapter 36 Question 1 Type: MCSA The nurse is examining a 12-month-old who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red, scaly plaques and small papules. Satellite lesions are also present. This is most likely caused by which of the following?

1. Candida albicans (yeast) 2. Impetigo (staph) 3. Infrequent diapering 4. Urine and feces Correct Answer: 1 Rationale 1: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red, scaly plaques with sharp margins.

Small papules and pustules might be seen, along with satellite lesions.

Rationale 2: Even though diaper dermatitis can be caused by impetigo, urine, feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

Rationale 3: Infrequent diapering, along with urine and feces, can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida.

Rationale 4: Urine and feces can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-2 Question 2 Type: MCSA

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The school nurse is conducting pediculosis capitis (head lice) checks. Which finding would indicate a "positive" head check?

1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area Correct Answer: 4 Rationale 1: Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Rationale 2: Lesions might be present from itching, but the positive sign of head lice is evidence of nits.

Rationale 3: Lesions might be present from itching, but the positive sign of head lice is evidence of nits.

Rationale 4: Evidence of pediculosis capitis includes silver/white sacs (nits) that are attached to the hair shafts, frequently in the occiput area.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-2 Question 3 Type: MCSA The 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What would the nurse expect to see while changing the child’s dressing and assessing the wound?

1. The wound is contracting, and the edges are growing together.

2. A blood clot has formed, sealing the wound.

3. Epithelial cells are growing into the wound.

4. The wound is pale and weepy.

Correct Answer: 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Wound contraction and inward movement of the wound edge occur during the reconstruction phase of wound healing.

Rationale 2: Clot formation to seal the wound with fibrin and trapped cells and platelets occurs during the inflammation phase of wound healing, in the first three to five days.

Rationale 3: Epithelial cells growing into the wound occurs in the reconstruction phase of wound healing.

Rationale 4: During the initial phase of healing, there is increased blood flow, giving the area an “inflamed” appearance.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-3 Question 4 Type: MCMA A child had an appendectomy and was discharged home at 48 hours postoperative. A week later the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child?

Standard Text: Select all that apply.

1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia 6. Corticosteroid therapy Correct Answer: 1,2,4,5,6 Rationale 1: Infection can affect healing and cause excessive scarring.

Rationale 2: Conditions such as diabetes affect circulating blood volume and are known to affect healing.

Rationale 3: Hypovolemia, not hypervolemia, would inhibit inflammation due to low circulating blood volume.

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Rationale 4: Poor nutrition without proper protein and calorie intake will affect healing.

Rationale 5: Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation.

Rationale 6: Corticosteroid therapy or other immunocompromising therapy will prevent macrophages from migrating to the site of injury and suppress epithelialization.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-3 Question 5 Type: MCSA The nurse is planning care for a three-month-old infant with eczema. Which intervention would take top priority in this infant's care?

1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions Correct Answer: 4 Rationale 1: Antibiotics are not routinely applied to the lesions since the lesions are not related to infection.

However, impaired skin barrier function and cutaneous immunity place the infant at greater risk for the development of skin infection.

Rationale 2: Keeping the infant content is not as high a priority as is prevention of infection. An infant with eczema is at a greater risk for the development of skin infection.

Rationale 3: Maintaining adequate nutrition is important, but it is not as high a priority. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infection.

Rationale 4: Nursing care should focus on preventing infection of lesions. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-4 Question 6 Type: MCSA An infant has a severe case of oral thrush (Candida albicans). Which is the priority nursing diagnosis for this infant?

1. Ineffective infant feeding pattern related to discomfort 2. Ineffective breathing pattern related to oral thrush 3. Activity intolerance related to oral thrush 4. Ineffective airway clearance related to mucus Correct Answer: 1 Rationale 1: An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern.

Rationale 2: Ineffective breathing pattern is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed.

Rationale 3: Activity intolerance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed.

Rationale 4: Ineffective airway clearance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 36-6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 7 Type: MCSA Parents understand the teaching a nurse has done with regard to care of their child with tinea capitis (ringworm of the scalp) if they state: 1. "We will give the griseofulvin with milk or peanut butter."

2. "We're glad ringworm isn't transmitted from person to person."

3. "Once the lesion is gone, we can stop the griseofulvin."

4. “Well, at least we don’t have to worry about the family cat getting the ringworm.”

Correct Answer: 1 Rationale 1: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption.

Rationale 2: All members of the family and household pets should be assessed for fungal lesions because personto-person transmission is common.

Rationale 3: The medication must be used for the entire prescribed period, even if the lesions are gone.

Rationale 4: Dogs and cats can develop the fungal lesions and be sources of spread of the organism.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-6 Question 8 Type: MCSA A nurse is applying a 5% permethrin lotion to a toddler with scabies. Which instruction describes the best way to apply this lotion?

1. Apply the lotion over the entire body from the chin down, as well as on the scalp and forehead.

2. Apply the lotion only on the areas with evidence of scabies activity.

3. Apply the lotion only to the hands.

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4. Apply the lotion to the scalp only.

Correct Answer: 1 Rationale 1: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Rationale 2: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead.

Rationale 3: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, including the scalp and forehead.

Rationale 4: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-6 Question 9 Type: MCSA A child has sustained a minor burn. Which of the following should be included in increased amounts in the child's diet?

1. Protein 2. Minerals 3. Carbohydrates 4. Fats Correct Answer: 1 Rationale 1: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet.

This is necessary to meet the increased nutritional requirements of healing.

Rationale 2: A high-calorie, high-protein diet is required to meet the increased nutritional requirements for healing.

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Rationale 3: The family should be taught that a high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing.

Rationale 4: A high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-7 Question 10 Type: MCSA Which would be the priority nursing diagnosis during the acute phase of burn injury for a child who has a thirddegree circumferential burn of the right arm?

1. Altered tissue perfusion, risk for 2. Infection, risk for 3. Impaired physical mobility 4. Altered nutrition: less than body requirements, risk for Correct Answer: 1 Rationale 1: Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered tissue perfusion to the extremity is the greatest risk and therefore the priority diagnosis.

Rationale 2: When the burn is circumferential, blood flow can become restricted due to edema and can result in tissue hypoxia; therefore, the priority diagnosis is altered tissue perfusion, risk for to the extremity. Risk of infection would be a secondary priority in this case.

Rationale 3: Impaired physical mobility is a secondary priority for the child with a circumferential burn. Edema to the area can result in restricted blood flow and tissue hypoxia, making the priority diagnosis altered tissue perfusion, risk for.

Rationale 4: Infection, nutrition, and mobility would have secondary priority in this case.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 36-7 Question 11 Type: MCSA The toddler pulled a pot of boiling water off the stove and suffered partial and full thickness burns to the chest.

EMS arrived, stabilized the child, and transported him to the hospital burn unit. The child is now in the recoverymanagement phase of burn treatment. Which is the most common complication seen in this period?

1. Asphyxia 2. Metabolic acidosis 3. Shock 4. Burn-wound infection Correct Answer: 4 Rationale 1: Asphyxia is not a common complication during the recovery-management phase of burn treatment.

Infection of the burned area is a frequent complication.

Rationale 2: Metabolic acidosis is not common in the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication.

Rationale 3: Shock is not the most common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication.

Rationale 4: Infection of the burned area is a frequent complication in the recovery-management phase. A goal of burn-wound care is protection from infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-7 Question 12 Type: MCSA The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication?

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1. Pain 2. Hypertrophic scarring 3. Poor circulation 4. Formation of thrombus in the burn area Correct Answer: 2 Rationale 1: The Jobst stockings or pressure garments do not prevent pain. They are used to prevent development of hypertrophic scarring and contractures.

Rationale 2: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.

Rationale 3: The Jobst pressure garments are used to prevent or minimize the development of hypertrophic scarring and contractures.

Rationale 4: The elastic pressure garments are used to prevent development of hypertrophic scarring and contractures. They do not prevent the formation of thrombus in the burn area.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-7 Question 13 Type: MCSA Nursing care of the child with a snake bite involves assessment of the child for initial and progressive signs of envenomation. Which is the priority nursing action at this time?

1. Measure the circumference of the extremity containing the bite every 20 to 30 minutes.

2. Assess immunization status.

3. Assess the need for emergency breathing interventions.

4. Assess neurovascular status and vital signs.

5. Assess pain and the child's response to pain medication.

Correct Answer: 3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: In order to track progression in swelling and response to treatment, the extremity with the bite is measured every 20 to 30 minutes. However, this does not take priority over airway, breathing, and circulation.

Rationale 2: Immunization status is important information to obtain, but the more immediate need is for airway, breathing, and circulation.

Rationale 3: Emergency intervention for airway, breathing, and circulation take priority and has a high probability of occurrence.

Rationale 4: Vital signs and neurovascular status of the distal extremities should be monitored but do not take priority over airway, breathing, and circulation.

Rationale 5: Pain medication will need to be given and the response to the treatment monitored; however, this should not take priority over airway, breathing, and circulation.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-8 Question 14 Type: MCSA The nurse is teaching strategies to prevent insect bites and stings to the parents of a small child. Which statement made by the parents indicates a need for further teaching?

1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her."

2. "We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction."

3. "My child can use insect repellent containing DEET of 10% or less."

4. "My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them."

Correct Answer: 1 Rationale 1: Bright-colored clothing and floral prints attract the insects. White and light-colored clothing should be worn. This statement requires clarification.

Rationale 2: Standing water is a breeding ground for mosquitoes. Rid yards of all bird baths, stagnant pools, and any standing water that mosquitoes could use for breeding. No clarification is needed.

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Rationale 3: DEET is an appropriate insect repellent and can be used in children. A concentration of 10% or less is recommended due to neurotoxic effects at greater concentrations. No clarification is needed.

Rationale 4: Heavy colognes, perfumes, soaps, and detergents resemble flowers and plants and will attract the stinging insects. This statement is correct.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-8 Question 15 Type: MCSA Following an automobile accident, a teenager is left paraplegic. The child is being prepared for discharge. The nurse is reviewing instructions to avoid decubitus ulcers on the buttocks and instructs the teenager to: 1. Contract the buttock muscles five times every two hours.

2. Increase fat in the diet to provide a protective coating over the boney prominences.

3. Do wheelchair push-ups every 15 to 30 minutes.

4. Avoid use of sheepskin as it prevents air from reaching the area.

Correct Answer: 3 Rationale 1: The child is a paraplegic and therefore unable to contract the buttock muscles.

Rationale 2: Extra weight will add to pressure on the boney prominences and should be avoided.

Rationale 3: Lifting the buttocks with the arms can help with blood flow to the buttocks and reduce the risk of breakdown.

Rationale 4: Sheepskin can reduce pressure on the buttocks; it is one of many pressure reducing materials available.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 36-3 Question 16 Type: MCMA While preparing for the day in the integument clinic, the nurse notices that a number of the patients being seen that day have conditions with a genetic component. Which skin conditions have a genetic or inherited component?

Standard Text: Select all that apply.

1. Atopic dermatitis 2. Seborrheic dermatitis 3. Epidermolysis bullosa 4. Molluscum contagiosum 5. Psoriasis Correct Answer: 1,3,5 Rationale 1: Atopic dermatitis is an allergic skin disorder. Allergies have an inherited component.

Rationale 2: Seborrheic dermatitis is thought to be an overgrowth of yeast and is influenced by hormones. It is not inherited.

Rationale 3: Epidermolysis bullosa is inherited either as autosomal dominant or autosomal recessive depending on type.

Rationale 4: Mulluscum is caused by a poxvirus and is transmitted person to person.

Rationale 5: Psoriasis is usually seen in patients with a family history. A multifactorial inheritance is suspected.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-4 Question 17 Type: MCSA

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The mother of several children is talking with the nurse. She asks the nurse why her younger child seems to sunburn easier than her older children. The nurse would explain that the skin of younger children: 1. Is thinner than that of adolescents.

2. Has less melanin.

3. Has smaller, nonfunctional apocrine sweat glands.

4. More readily absorbs chemicals.

Correct Answer: 2 Rationale 1: The skin of infants is thinner than adolescents, but that does not explain why they are more susceptible to sunburns.

Rationale 2: Melanin determines skin color and serves as a shield against ultraviolet radiation, the cause of sunburns.

Rationale 3: Although accurate information, it does not explain why the child is more prone to sunburns.

Rationale 4: While true, this does not explain why infants are more prone to sunburns.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-1 Question 18 Type: MCSA The clinic nurse has completed teaching the teenager about skin care and acne prevention. Which statement by the teenager indicates the need for additional teaching?

1. “I shouldn’t squeeze my blackheads or pimples.”

2. “I need to watch my diet and cut out all chocolates.”

3. “I should avoid applying drying materials, such as astringents, to my face” 4. “I should wash my hands frequently and avoid touching my face.”

Correct Answer: 2,4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: This practice can introduce organisms into the lesions and should be avoided. This statement needs no clarification.

Rationale 2: There has been no research that connects diet to acne. A healthy diet with protein is recommended, but chocolate does not have to be excluded. This statement needs to be clarified.

Rationale 3: This statement is accurate and needs no clarification.

Rationale 4: This is an important means of reducing facial irritation.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-5 Question 19 Type: MCSA A three-year-old is admitted to the hospital unit with cellulitis of the neck. The nurse will expect medical treatment to include: 1. Topical antibiotics.

2. Intravenous antibiotics.

3. Incision and drainage.

4. Intravenous corticosteroids.

Correct Answer: 2 Rationale 1: This is an infection of the deeper tissues including the dermis and supporting connective tissues.

Topical antibiotics will not reach the infection.

Rationale 2: This infection usually requires parenteral antibiotics.

Rationale 3: The infection is not consolidated into an abscess, so an incision and drainage would not be performed.

Rationale 4: Corticosteroids are anti-inflammatories and would not be used to treat this infection.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-6 Question 20 Type: MCMA There has been an outbreak of tinea pedis among the high school football team. The school nurse meets with the team and discusses preventative activities to reduce spread of the organism. The nurse will instruct the team members to: Standard Text: Select all that apply.

1. Wear 100% white cotton socks, changed twice a day.

2. Use talc on feet daily.

3. Use an over-the-counter corticosteroid cream to treat the area.

4. Wear foot covers such as flip flops in the locker room and shower.

5. Apply heat to the area twice a day.

Correct Answer: 1,2,4 Rationale 1: The socks will wick moisture away from the feet to promote healing.

Rationale 2: This process will help keep the feet dry.

Rationale 3: Corticosteroids will not destroy the organism. An antifungal medication is required.

Rationale 4: This will reduce the spread of the organism among team members.

Rationale 5: Heat will not treat the problem. Antifungal medications are required.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-6

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