Principles of Pediatric Nursing 6th Ed By Ball-Test Bank

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Principles of Pediatric Nursing 6th Ed By Ball-Test Bank

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 2

Question 1

Type: MCMA

The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family?

Standard Text: Select all that apply.

  1. Making all ADL decisions for the adolescent and family
  2. Asking the adolescent what foods to include during meal time
  3. Allowing the family time to pray each day with the adolescent
  4. Encouraging the adolescent’s friends to visit during visiting hours
  5. Leaving all questions for the healthcare provider

Correct Answer: 2,3,4

Rationale 1: Interventions that will enhance family-centered care for this client and family include asking the adolescent to be an active member of care by making food choices, allowing the family to pray each day with the adolescent, and encouraging the adolescent’s friends to visit during visiting hours. These interventions each promote the concepts of family-centered care. Making all decisions for the adolescent and family and leaving all questions for the healthcare provider do not promote the concepts of family-centered care.

Rationale 2: Interventions that will enhance family-centered care for this client and family include asking the adolescent to be an active member of care by making food choices, allowing the family to pray each day with the adolescent, and encouraging the adolescent’s friends to visit during visiting hours. These interventions each promote the concepts of family-centered care. Making all decisions for the adolescent and family and leaving all questions for the healthcare provider do not promote the concepts of family-centered care.

Rationale 3: Interventions that will enhance family-centered care for this client and family include asking the adolescent to be an active member of care by making food choices, allowing the family to pray each day with the adolescent, and encouraging the adolescent’s friends to visit during visiting hours. These interventions each promote the concepts of family-centered care. Making all decisions for the adolescent and family and leaving all questions for the healthcare provider do not promote the concepts of family-centered care.

Rationale 4: Interventions that will enhance family-centered care for this client and family include asking the adolescent to be an active member of care by making food choices, allowing the family to pray each day with the adolescent, and encouraging the adolescent’s friends to visit during visiting hours. These interventions each promote the concepts of family-centered care. Making all decisions for the adolescent and family and leaving all questions for the healthcare provider do not promote the concepts of family-centered care.

Global Rationale: Interventions that will enhance family-centered care for this client and family include asking the adolescent to be an active member of care by making food choices, allowing the family to pray each day with the adolescent, and encouraging the adolescent’s friends to visit during visiting hours. These interventions each promote the concepts of family-centered care. Making all decisions for the adolescent and family and leaving all questions for the healthcare provider do not promote the concepts of family-centered care.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 2.7 Develop a family-centered nursing care plan for the child and family.

 

Question 2

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. Which action best implements family-centered care?

  1. Telling the family what must be done for the family’s health
  2. Assuming the role of an expert professional to direct the health care
  3. Intervening for the child and family as a unit
  4. Conferring with the family in deciding which healthcare option will be chosen

Correct Answer: 4

Rationale 1: 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. In family-focused care, the healthcare worker assumes the role of professional expert while missing the multiple contributions the family brings to the healthcare meeting.

Rationale 2: 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. In family-focused care, the healthcare worker assumes the role of professional expert while missing the multiple contributions the family brings to the healthcare meeting.

Rationale 3: 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. In family-focused care, the healthcare worker assumes the role of professional expert while missing the multiple contributions the family brings to the healthcare meeting.

Rationale 4: 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. In family-focused care, the healthcare worker assumes the role of professional expert while missing the multiple contributions the family brings to the healthcare meeting.

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

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 2.1 Describe key concepts of family-centered care.

 

Question 3

Type: MCSA

A school-age client tells you that “Grandpa, Mommy, Daddy, and my brother live at my house.” Which type of family will the nurse identify in the medical record based on this description?

  1. Binuclear family
  2. Extended family
  3. Gay or lesbian family
  4. Traditional nuclear family

Correct Answer: 2

Rationale 1: An extended family contains a parent or a couple who share the house with their children and another adult relative. A binuclear family includes the divorced parents who have joint custody of their biologic children, while the children alternate spending varying amounts of time in the home of each parent. A gay or lesbian family is comprised of two same-sex domestic partners; they may or may not have children. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biologic children of this union.

Rationale 2: An extended family contains a parent or a couple who share the house with their children and another adult relative. A binuclear family includes the divorced parents who have joint custody of their biologic children, while the children alternate spending varying amounts of time in the home of each parent. A gay or lesbian family is comprised of two same-sex domestic partners; they may or may not have children. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biologic children of this union.

Rationale 3: An extended family contains a parent or a couple who share the house with their children and another adult relative. A binuclear family includes the divorced parents who have joint custody of their biologic children, while the children alternate spending varying amounts of time in the home of each parent. A gay or lesbian family is comprised of two same-sex domestic partners; they may or may not have children. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biologic children of this union.

Rationale 4: An extended family contains a parent or a couple who share the house with their children and another adult relative. A binuclear family includes the divorced parents who have joint custody of their biologic children, while the children alternate spending varying amounts of time in the home of each parent. A gay or lesbian family is comprised of two same-sex domestic partners; they may or may not have children. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biologic children of this union.

Global Rationale: An extended family contains a parent or a couple who share the house with their children and another adult relative. A binuclear family includes the divorced parents who have joint custody of their biologic children, while the children alternate spending varying amounts of time in the home of each parent. A gay or lesbian family is comprised of two same-sex domestic partners; they may or may not have children. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biologic children of this union.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.2 Identify characteristics of different types of families.

 

Question 4

Type: MCSA

The nurse is performing an assessment of a child’s biologic family history. Which situation would necessitate the nurse’s asking the mother for information should use the term “child’s father” instead of “your husband”?

  1. Traditional nuclear family
  2. Traditional extended family
  3. Two-income nuclear family
  4. Cohabitating informal stepfamily

Correct Answer: 4

Rationale 1: The mother from the cohabitating informal stepfamily does not have a husband; the nurse should be asking about the “child’s father.” In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

Rationale 2: The mother from the cohabitating informal stepfamily does not have a husband; the nurse should be asking about the “child’s father.” In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

Rationale 3: The mother from the cohabitating informal stepfamily does not have a husband; the nurse should be asking about the “child’s father.” In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the child’s father is the same person as the mother’s husband.

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

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

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.2 Identify characteristics of different types of families.

 

Question 5

Type: MCSA

Several children arrived at the emergency department accompanied only by their fathers. Which father may legally sign emergency medical consent for treatment?

  1. The divorced one from the binuclear family
  2. The stepfather from the blended or reconstituted family
  3. The divorced one when the single-parent mother has custody
  4. The nonbiologic one from the heterosexual cohabitating family

Correct Answer: 1

Rationale 1: The divorced father from the binuclear family may sign informed consent because he has equal legal rights with the mother under joint-custody arrangements. The nonbiologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the nonbiologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

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

Rationale 3: The divorced father from the binuclear family may sign informed consent because he has equal legal rights with the mother under joint-custody arrangements. The nonbiologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the nonbiologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

Rationale 4: The divorced father from the binuclear family may sign informed consent because he has equal legal rights with the mother under joint-custody arrangements. The nonbiologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the nonbiologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

Global Rationale: The divorced father from the binuclear family may sign informed consent because he has equal legal rights with the mother under joint-custody arrangements. The nonbiologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the nonbiologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 2.2 Identify characteristics of different types of families.

 

Question 6

Type: MCSA

The community-health nurse is assessing several families for various strengths and needs in regard to after-school and backup child-care arrangements. Which family type will benefit the most from this assessment and subsequent interventions?

  1. The binuclear family
  2. The extended family
  3. The single-parent family
  4. The traditional nuclear family

Correct Answer: 3

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

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

Rationale 3: The single-parent family most typically lacks social, emotional, and financial resources. Nursing considerations for such families should include referrals to options that will enable the parent to fulfill work commitments while providing the child with access to resources that can support the child’s growth and development. The binuclear family, the extended family, and the traditional nuclear family generally have at least two adults who can share in the care and the 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. The binuclear family, the extended family, and the traditional nuclear family generally have at least two adults who can share in the care and the nurturing of its children.

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

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.2 Identify characteristics of different types of families.

 

Question 7

Type: MCSA

The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions?

  1. Authoritarian one
  2. Authoritative one
  3. Indifferent one
  4. Permissive one

Correct Answer: 2

Rationale 1: The parenting style that results in positive outcomes for the behavior and learning of its children is the authoritative style. 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. Children in the authoritarian parenting family are denied opportunity to develop some skills in the areas of self-direction, communication, and negotiation. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

Rationale 2: The parenting style that results in positive outcomes for the behavior and learning of its children is the authoritative style. 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. Children in the authoritarian parenting family are denied opportunity to develop some skills in the areas of self-direction, communication, and negotiation. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

Rationale 3: The parenting style that results in positive outcomes for the behavior and learning of its children is the authoritative style. 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. Children in the authoritarian parenting family are denied opportunity to develop some skills in the areas of self-direction, communication, and negotiation. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

Rationale 4: The parenting style that results in positive outcomes for the behavior and learning of its children is the authoritative style. 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. Children in the authoritarian parenting family are denied opportunity to develop some skills in the areas of self-direction, communication, and negotiation. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

Global Rationale: The parenting style that results in positive outcomes for the behavior and learning of its children is the authoritative style. 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. Children in the authoritarian parenting family are denied opportunity to develop some skills in the areas of self-direction, communication, and negotiation. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 2.3 Contrast four different parenting styles and analyze their impact on child personality development.

 

Question 8

Type: MCSA

The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which family style will the nurse most likely document in this situation?

  1. Authoritarian
  2. Authoritative
  3. Indifferent
  4. Permissive

Correct Answer: 3

Rationale 1: Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children. Parents who favor the authoritarian style may exhibit a punitive attitude toward the child who is misbehaving but are not disinterested. Parents employing the authoritative style and the permissive style have children who report that “my parent loves me and shows affection regularly.”

Rationale 2: Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children. Parents who favor the authoritarian style may exhibit a punitive attitude toward the child who is misbehaving but are not disinterested. Parents employing the authoritative style and the permissive style have children who report that “my parent loves me and shows affection regularly.”

Rationale 3: Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children. Parents who favor the authoritarian style may exhibit a punitive attitude toward the child who is misbehaving but are not disinterested. Parents employing the authoritative style and the permissive style have children who report that “my parent loves me and shows affection regularly.”

Rationale 4: Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children. Parents who favor the authoritarian style may exhibit a punitive attitude toward the child who is misbehaving but are not disinterested. Parents employing the authoritative style and the permissive style have children who report that “my parent loves me and shows affection regularly.”

Global Rationale: Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children. Parents who favor the authoritarian style may exhibit a punitive attitude toward the child who is misbehaving but are not disinterested. Parents employing the authoritative style and the permissive style have children who report that “my parent loves me and shows affection regularly.”

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.3 Contrast four different parenting styles and analyze their impact on child personality development.

 

Question 9

Type: MCSA

The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description?

  1. Time out
  2. Reasoning
  3. Behavior modification
  4. Experiencing consequences of misbehavior

Correct Answer: 3

Rationale 1: Behavior modification identifies and gives rewards for desired behaviors. Time out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes. Reasoning attempts to use explanation to end misbehavior.

Rationale 2: Behavior modification identifies and gives rewards for desired behaviors. Time out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes. Reasoning attempts to use explanation to end misbehavior.

Rationale 3: Behavior modification identifies and gives rewards for desired behaviors. Time out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes. Reasoning attempts to use explanation to end misbehavior.

Rationale 4: Behavior modification identifies and gives rewards for desired behaviors. Time out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes. Reasoning attempts to use explanation to end misbehavior.

Global Rationale: Behavior modification identifies and gives rewards for desired behaviors. Time out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes. Reasoning attempts to use explanation to end misbehavior.

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 2.3 Contrast four different parenting styles and analyze their impact on child personality development.

 

Question 10

Type: MCSA

The nurse is assessing a family’s effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family?

  1. Family-stress theory
  2. Family-development theory
  3. Family-systems theory
  4. Family life-cycle theory

Correct Answer: 1

Rationale 1: Family-stress theory indicates an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families. Family-development theory suggests developmental tasks for families in each stage. Family-systems theory looks at the relationships among and between family members and the environment. The family life cycle is not a family social system theory.

Rationale 2: Family-stress theory indicates an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families. Family-development theory suggests developmental tasks for families in each stage. Family-systems theory looks at the relationships among and between family members and the environment. The family life cycle is not a family social system theory.

Rationale 3: Family-stress theory indicates an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families. Family-development theory suggests developmental tasks for families in each stage. Family-systems theory looks at the relationships among and between family members and the environment. The family life cycle is not a family social system theory.

Rationale 4: Family-stress theory indicates an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families. Family-development theory suggests developmental tasks for families in each stage. Family-systems theory looks at the relationships among and between family members and the environment. The family life cycle is not a family social system theory.

Global Rationale: Family-stress theory indicates an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families. Family-development theory suggests developmental tasks for families in each stage. Family-systems theory looks at the relationships among and between family members and the environment. The family life cycle is not a family social system theory.

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.5 List the categories of family strengths that help families develop and cope with stressors.

 

Question 11

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 the mother has just accepted a temporary waitress job. Which nursing diagnosis will the nurse use when planning care for this child and family?

  1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors
  2. Impaired Social Interaction (Parent and Child) Related to the Lack of Family or Respite Support
  3. Interrupted Family Processes Related to Child with Significant Disability Requiring Alteration in Family Functioning
  4. Risk for Caregiver Role Strain Related to Child with a Newly Acquired Disability and the Associated Financial Burden

Correct Answer: 1

Rationale 1: Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors best fits the multiple crises to which this family is responding. The spica cast may require alteration in family functioning; however, fractures are generally not considered a significant long-term disability. Lack of family members and lack of respite support was not mentioned in the scenario.

Rationale 2: Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors best fits the multiple crises to which this family is responding. The spica cast may require alteration in family functioning; however, fractures are generally not considered a significant long-term disability. Lack of family members and lack of respite support was not mentioned in the scenario.

Rationale 3: Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors best fits the multiple crises to which this family is responding. The spica cast may require alteration in family functioning; however, fractures are generally not considered a significant long-term disability. Lack of family members and lack of respite support was not mentioned in the scenario.

Rationale 4: Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors best fits the multiple crises to which this family is responding. The spica cast may require alteration in family functioning; however, fractures are generally not considered a significant long-term disability. Lack of family members and lack of respite support was not mentioned in the scenario.

Global Rationale: Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors best fits the multiple crises to which this family is responding. The spica cast may require alteration in family functioning; however, fractures are generally not considered a significant long-term disability. Lack of family members and lack of respite support was not mentioned in the scenario.

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 2.6 Summarize the advantages of using a family or cultural assessment tool.

 

Question 12

Type: MCSA

A nurse is working with the family of a pediatric client. When planning to obtain an accurate family assessment, which initial step is the most appropriate?

  1. Establish a trusting relationship with the family.
  2. Select the most relevant family-assessment tool.
  3. Focus primarily upon the mother, while learning her greatest concern.
  4. Observe the family in the home setting, since this step always proves indispensable.

Correct Answer: 1

Rationale 1: Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment. There is benefit when the tool used matches the family’s strengths and resources; however, selecting the most relevant family-assessment tool is not indispensable to accuracy in the assessment. Focusing primarily upon the mother while learning her greatest concern is counterproductive and prevents the nurse from acknowledging multiple perceptions held by the family’s members. Observing the family in the home setting is only recommended in some cases.

Rationale 2: Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment. There is benefit when the tool used matches the family’s strengths and resources; however, selecting the most relevant family-assessment tool is not indispensable to accuracy in the assessment. Focusing primarily upon the mother while learning her greatest concern is counterproductive and prevents the nurse from acknowledging multiple perceptions held by the family’s members. Observing the family in the home setting is only recommended in some cases.

Rationale 3: Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment. There is benefit when the tool used matches the family’s strengths and resources; however, selecting the most relevant family-assessment tool is not indispensable to accuracy in the assessment. Focusing primarily upon the mother while learning her greatest concern is counterproductive and prevents the nurse from acknowledging multiple perceptions held by the family’s members. Observing the family in the home setting is only recommended in some cases.

Rationale 4: Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment. There is benefit when the tool used matches the family’s strengths and resources; however, selecting the most relevant family-assessment tool is not indispensable to accuracy in the assessment. Focusing primarily upon the mother while learning her greatest concern is counterproductive and prevents the nurse from acknowledging multiple perceptions held by the family’s members. Observing the family in the home setting is only recommended in some cases.

Global Rationale: Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment. There is benefit when the tool used matches the family’s strengths and resources; however, selecting the most relevant family-assessment tool is not indispensable to accuracy in the assessment. Focusing primarily upon the mother while learning her greatest concern is counterproductive and prevents the nurse from acknowledging multiple perceptions held by the family’s members. Observing the family in the home setting is only recommended in some cases.

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.6 Summarize the advantages of using a family or cultural assessment tool.

 

Question 13

Type: MCSA

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

  1. Children whose parents divorced recently
  2. Children who gained a stepparent recently
  3. Children recently placed into foster care
  4. Children adopted as infants

Correct Answer: 3

Rationale 1: Children in foster care are more likely to have problems perceiving a sense of belonging. Children whose parents divorce often fear abandonment. Children who gain a stepparent may have problems trusting the new parent. Infants who are adopted at birth can have minimal problems with acceptance when parents follow preadoption counseling about disclosure.

Rationale 2: Children in foster care are more likely to have problems perceiving a sense of belonging. Children whose parents divorce often fear abandonment. Children who gain a stepparent may have problems trusting the new parent. Infants who are adopted at birth can have minimal problems with acceptance when parents follow preadoption counseling about disclosure.

Rationale 3: Children in foster care are more likely to have problems perceiving a sense of belonging. Children whose parents divorce often fear abandonment. Children who gain a stepparent may have problems trusting the new parent. Infants who are adopted at birth can have minimal problems with acceptance when parents follow preadoption counseling about disclosure.

Rationale 4: Children in foster care are more likely to have problems perceiving a sense of belonging. Children whose parents divorce often fear abandonment. Children who gain a stepparent may have problems trusting the new parent. Infants who are adopted at birth can have minimal problems with acceptance when parents follow preadoption counseling about disclosure.

Global Rationale: Children in foster care are more likely to have problems perceiving a sense of belonging. Children whose parents divorce often fear abandonment. Children who gain a stepparent may have problems trusting the new parent. Infants who are adopted at birth can have minimal problems with acceptance when parents follow preadoption counseling about disclosure.

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.4 Explain the effects of major family changes on children.

 

Question 14

Type: MCSA

There are several tools that help with obtaining a cultural assessment of a client and his family. Which tool would be appropriate to gather 12 major concepts of cultural assessment?

  1. Sunrise enabler
  2. Model for cultural competence
  3. Transcultural assessment model
  4. Health traditions model

Correct Answer: 2

Rationale 1: The sunrise enabler examines influences on care and culture. The model for cultural competence will gather information on 12 major concepts. The transcultural assessment model is based on 6 phenomena. The health traditions model is predicated on holistic health.

Rationale 2: The sunrise enabler examines influences on care and culture. The model for cultural competence will gather information on 12 major concepts. The transcultural assessment model is based on 6 phenomena. The health traditions model is predicated on holistic health.

Rationale 3: The sunrise enabler examines influences on care and culture. The model for cultural competence will gather information on 12 major concepts. The transcultural assessment model is based on 6 phenomena. The health traditions model is predicated on holistic health.

Rationale 4: The sunrise enabler examines influences on care and culture. The model for cultural competence will gather information on 12 major concepts. The transcultural assessment model is based on 6 phenomena. The health traditions model is predicated on holistic health.

Global Rationale: The sunrise enabler examines influences on care and culture. The model for cultural competence will gather information on 12 major concepts. The transcultural assessment model is based on 6 phenomena. The health traditions model is predicated on holistic health.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.6 Summarize the advantages of using a family or cultural assessment tool.

 

Question 15

Type: MCSA

Cultures have many different childrearing practices. Which culture is known to value the male child more than the female child, and often teaches children to avoid displaying emotion?

  1. Mexican
  2. Amish
  3. Chinese
  4. Navajo

Correct Answer: 3

Rationale 1: The Chinese culture values the male child more than the female child, and often teaches children to avoid showing emotion. The other cultures do not have this component.

Rationale 2: The Chinese culture values the male child more than the female child, and often teaches children to avoid showing emotion. The other cultures do not have this component.

Rationale 3: The Chinese culture values the male child more than the female child, and often teaches children to avoid showing emotion. The other cultures do not have this component.

Rationale 4: The Chinese culture values the male child more than the female child, and often teaches children to avoid showing emotion. The other cultures do not have this component.

Global Rationale: The Chinese culture values the male child more than the female child, and often teaches children to avoid showing emotion. The other cultures do not have this component.

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 2.8 Describe cultural influences on the family’s beliefs about health, illness, and treatments.

 

 

Question 16

Type: MCMA

The nurse is planning care for a school-age client and family who have expressed wanting to use complementary and alternative modalities (CAM) in the treatment plan. Which interventions can the nurse safely implement into the plan of care?

Standard Text: Select all that apply.

  1. Substituting an herbal remedy for a prescribed medication
  2. Encouraging the parents to share which modalities they would like to implement
  3. Educating on the benefits and risks for each modality
  4. Using essential oils to decrease nausea
  5. Discouraging the use of faith-based therapies

Correct Answer: 2, 3, 4,

Rationale 1: Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

Rationale 2: Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

Rationale 3: Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

Rationale 4: Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

Rationale 5: Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

Global Rationale: Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 2.9 Discuss nursing interventions for providing culturally sensitive and competent care to the child and family.

 

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 8

Question 1

Type: MCMA

Which of these aspects of developmental health supervision should be included in each healthcare visit of young children?

Standard Text: Select all that apply.

  1. Assessment
  2. Discipline
  3. Education
  4. Intervention
  5. Toilet training

Correct Answer: 1,3,4

Rationale 1: The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

Rationale 2: The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

Rationale 3: The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

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 healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

Rationale 5: 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 healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

Global Rationale: 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 healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 2

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; however, nothing is effective. Which of these actions by the nurse takes priority?

  1. Instruct the father to hold the toddler down tightly to complete the examination.
  2. Allow the toddler to sit on the parent’s lap and begin the assessment.
  3. Allow the toddler to stand on the floor until he stops crying.
  4. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler’s behavior.

Correct Answer: 2

Rationale 1: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

Rationale 2: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

Rationale 3: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

Rationale 4: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

Global Rationale: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

 

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

Question 3

Type: MCSA

At a routine healthcare 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 the age.
  2. The toddler needs to eat more at each feeding.
  3. The height and weight are disproportionate, and the toddler needs further evaluation.
  4. The family is most likely short.

Correct Answer: 3

Rationale 1: 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 is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may 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 is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing.

Rationale 3: Usually height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child’s height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing.

Rationale 4: 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 is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing.

Global Rationale: 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 is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers:growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 4

Type: MCSA

A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take?

  1. Perform the assessment from head to toe.
  2. Leave intrusive procedures such as ear and eye examinations until the end.
  3. Explain each part of the examination to the child before performing it.
  4. Ask the mother to tell the child not to be afraid.

Correct Answer: 2

Rationale 1: 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 includes the heart and lungs.

Rationale 2: Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs.

Rationale 3: 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 includes the heart and lungs.

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 includes the heart and lungs.

Global Rationale: 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 includes the heart and lungs.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

Question 5

Type: MCMA

Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old?

Standard Text: Select all that apply.

  1. Always feeds self
  2. Scribbles and draws on paper
  3. Kicks a ball
  4. Throws ball overhand
  5. Goes up and down stairs

Correct Answer: 2,3,5

Rationale 1: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

Rationale 2: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

Rationale 3: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

Rationale 4: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

Rationale 5: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

Global Rationale: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers:growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 6

Type: MCSA

A nurse observes the parent/child interaction during the 4-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial?

  1. “Perhaps you should leave the room so that I can speak with your child privately.”
  2. “I am going to refer you for counseling since your interactions with your child seem so negative.”
  3. “Let’s talk privately. Let’s discuss the way you speak with your child and possible ways to be more positive.”
  4. Addressing the child, the nurse says, “Are you unhappy when Mommy talks to you like this?”

Correct Answer: 3

Rationale 1: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is “unhappy” with the parent.

Rationale 2: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is “unhappy” with the parent.

Rationale 3: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is “unhappy” with the parent.

Rationale 4: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is “unhappy” with the parent.

Global Rationale: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is “unhappy” with the parent.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.4 Discuss the importance of family in child health care, and include family assessment in each health supervision visit.

 

Question 7

Type: MCSA

A nurse who is the manager of an ambulatory pediatric healthcare center is planning protocols for the routine healthcare visits of the children. Children at this care center have a high incidence of obesity. At which age should the nurses at this clinic calculate the body mass index (BMI) for all pediatric clients?

  1. 12 months
  2. 24 months
  3. 36 months
  4. 4 years

Correct Answer: 2

Rationale 1: The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

Rationale 2: The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

Rationale 3: The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

Rationale 4: The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

Global Rationale: The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

Question 8

Type: MCSA

Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile?

  1. Discussing the growth of the toddler as compared to the growth chart
  2. Suggesting ways to have the toddler eat higher calorie foods
  3. Instructing the mother to feed the toddler alone without any distractions such as TV or music
  4. Teaching the mother to avoid disciplining the toddler within one-half hour of eating

Correct Answer: 1

Rationale 1: Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

Rationale 2: Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

Rationale 3: Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

Rationale 4: Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

Global Rationale: Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 9

Type: MCSA

Parents of a preschool child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents?

  1. “Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child.”
  2. “Let’s talk about other forms of discipline that have a more positive effect on the child.”
  3. “Can you try only spanking the child every other day for one week and see how that affects the child’s behavior?”
  4. “I think you are not parenting your child properly, so let’s talk about ways to improve your parenting skills.”

Correct Answer: 2

Rationale 1: The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse’s response needs to reflect these feelings. To suggest spanking as 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 find a more positive way of influencing behavior in this age child. The nurse’s response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

Rationale 3: The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse’s response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

Rationale 4: The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse’s response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

Global Rationale: The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse’s response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.5 Integrate pertinent mental health care into health supervision visits for young children.

 

Question 10

Type: MCSA

A parent questions how her toddler plays with other toddlers. Which response by the nurse displays the best description of the differences in play between the toddler and the preschooler?

  1. Toddlers play side by side, while preschoolers play cooperatively.
  2. Toddlers play house and imitate adult roles, while preschoolers become the Mom or Dad while playing house.
  3. Toddlers play cooperatively, while preschoolers play interactive games.
  4. There are no differences between toddlers and preschoolers since both groups play cooperatively.

Correct Answer: 1

Rationale 1: Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

Rationale 2: Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

Rationale 3: Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

Rationale 4: Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

Global Rationale: Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

 

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 11

Type: MCSA

A mother of an 18-month old asks the nurse whether she can begin to introduce low-fat milk like the rest of the family drinks. The nurse answers the mother based on the knowledge that low-fat milk can safely be introduced at what age?

  1. 18 months
  2. 24 months
  3. 3 years
  4. 4 years

Correct Answer: 1

Rationale 1: Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk; and it can safely be introduced before ages 3 and 4.

Rationale 2: Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4.

Rationale 3: Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4.

Rationale 4: Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4.

Global Rationale: Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 12

Type: MCSA

The nurse is evaluating the car seat of a 3-year-old who weighs 42 pounds. Which recommendation should the nurse make about the car seat to the parents?

  1. Convertible, rear-facing seat
  2. Belt-positioning booster seat
  3. A car seat with a harness approved for higher weights and heights
  4. A regular seat with lap and shoulder strap

Correct Answer: 3

Rationale 1: The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher–weight/height children so that she is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

Rationale 2: The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher–weight/height children so that she is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

Rationale 3: The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher–weight/height children so that she is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

Rationale 4: The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher–weight/height children so that she is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

Global Rationale: The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher–weight/height children so that she is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

Question 13

Type: MCSA

During a clinic visit, the parents of a 15-month-old ask what disease and injury prevention topics would be appropriate to discuss at this age. Which response by the nurse is the most appropriate?

  1. “It’s never too early to teach a child to wear a helmet when riding a bicycle.”
  2. “Teaching simple handwashing is a good topic at this age.”
  3. “Tell the child over and over to stay away from water unless you are with him.”
  4. “Tell him firmly ‘no’ when he tries to cross the street.”

Correct Answer: 2

Rationale 1: Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations.

Rationale 2: Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations.

Rationale 3: Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations.

Rationale 4: Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations.

Global Rationale: Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

Question 14

Type: MCSA

Which assessment question would get the most accurate response when a nurse is assessing learning/reading skills in the early childhood years?

  1. “What rewards do you use when your child does something good?”
  2. “What is your child’s language like now?”
  3. “Does your child get along well with others?”
  4. “Do you keep books for your child readily available?”

Correct Answer: 4

Rationale 1: Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning/reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

Rationale 2: Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning/reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

Rationale 3: Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning/reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

Rationale 4: Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning/reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

Global Rationale: Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning/reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

Question 15

Type: MCMA

The nurse is asked to teach injury prevention measures to a classroom of 4-year-old preschoolers. Which teaching points are most appropriate at this age?

Standard Text: Select all that apply.

  1. Stop, drop and roll if clothes catch fire
  2. Never go into the road alone.
  3. Acceptable places for climbing
  4. Safe meeting place outside the house in case of fire
  5. Car seat safety

Correct Answer: 1,2,4,5

Rationale 1: Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

Rationale 2: Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

Rationale 3: Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

Rationale 4: Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

Rationale 5: Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

Global Rationale: Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.3 Plan health promotion and health maintenance strategies employed during health supervision visits of young children.

 

 

Question 16

Type: MCSA

The nurse is performing a well-child exam on a child who turned 4 years old 3 months ago. What can the nurse ask the child to do to assess appropriate milestones for this age?

  1. Jump up and down
  2. Throw a ball
  3. Stack three or more blocks
  4. Draw lines on paper

Correct Answer: 2

Rationale 1: Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4–5 years, a child begins to throw a ball overhand.

Rationale 2: Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4–5 years, a child begins to throw a ball overhand.

Rationale 3: Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4–5 years, a child begins to throw a ball overhand.

Rationale 4: Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4–5 years, a child begins to throw a ball overhand.

Global Rationale: Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4–5 years, a child begins to throw a ball overhand.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 8.1 Describe the areas of assessment and intervention for health supervision visits for toddlers and preschoolers: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 17

Type: MCMA

Which health promotion activities can the nurse recommend to the parents of a preschool-age child in order to enhance the child’s self-concept?

Standard Text: Select all that apply.

  1. Encourage a play date with a school-age child.
  2. Praise the child for staying dry at night.
  3. Tell the child there will be a punishment for bathroom accidents.
  4. Set aside time for the child each day.
  5. Discuss appropriate activities to engage in with the daycare provider.

Correct Answer: 2,4,5

 

Rationale 1: Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child’s unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler’s or preschooler’s developmental capabilities.

 

Rationale 2: Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child’s unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler’s or preschooler’s developmental capabilities.

 

Rationale 3: Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child’s unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler’s or preschooler’s developmental capabilities.

 

Rationale 4: Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child’s unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler’s or preschooler’s developmental capabilities.

 

Rationale 5: Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child’s unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler’s or preschooler’s developmental capabilities.

 

Global Rationale: Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child’s unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler’s or preschooler’s developmental capabilities.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 8.2 State components of self-concept for toddlers and preschoolers.

 

Question 18

Type: MCMA

 

The nurse is planning care for a preschool-age child and family. In order to assess the family, what should the nurse plan to do during each health supervision visit?

Standard Text: Select all that apply.

  1. Discuss of the child’s developmental status
  2. Observe interactions among the family members
  3. Discuss concerns with the parents
  4. Administer age appropriate vaccinations
  5. Record height and weight

Correct Answer: 1,2,3

Rationale 1: In order to assess the child and family, the nurse would plan to discuss the child’s developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

Rationale 2: In order to assess the child and family, the nurse would plan to discuss the child’s developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

Rationale 3: In order to assess the child and family, the nurse would plan to discuss the child’s developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

Rationale 4: In order to assess the child and family, the nurse would plan to discuss the child’s developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

Rationale 5: In order to assess the child and family, the nurse would plan to discuss the child’s developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

Global Rationale: In order to assess the child and family, the nurse would plan to discuss the child’s developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 8.4 Discuss the importance of family in child health care, and include family assessment in each health supervision visit.

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 16

Question 1

Type: MCSA

A nurse is providing information to a group of new mothers. Which statement best explains why newborns and young infants are more susceptible to infection?

  1. “They have high levels of maternal antibodies to diseases to which the mother has been exposed.”
  2. “They have passive transplacental immunity from maternal immunoglobulin G.”
  3. “They have immune systems that are not fully mature at birth.”
  4. “They have been exposed to microorganisms during the birth process.”

Correct Answer: 3

Rationale 1: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns’ and young infants’ high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Rationale 2: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns’ and young infants’ high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Rationale 3: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns’ and young infants’ high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Rationale 4: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns’ and young infants’ high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Global Rationale: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns’ and young infants’ high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.1 Compare the vulnerability of young children and adults to communicable diseases.

 

Question 2

Type: MCSA

 

The nurse is discussing ways to treat fever in the home environment to a group of parents in the community.  Which statement is appropriate for the nurse to include in the presentation?

  1. “Ibuprofen is the only effective means to reduce fever.”
  2. If the child requires more than one dose of acetaminophen antibiotics are needed.”
  3. “Purchase a new bottle of acetaminophen for your newborn because it will have recommended medication concentration.”
  4. “It is not necessary to follow the recommendations on the bottle of ibuprofen as this will not prevent an overdose for your child.”

Correct Answer: 3

Rationale 1: The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.

Rationale 2: The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.

Rationale 3: The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.

Rationale 4: The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.

Global Rationale: The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.8 Create a parent education session that addresses important considerations of giving acetaminophen or ibuprofen to infants and children with a fever.

 

Question 3

Type: MCSA

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse may also give which of immunizations during the same well-child-care appointment?

  1. Var (varicella)
  2. TIV (influenza)
  3. MMR (measles, mumps, rubella)
  4. Haemophilus influenza type B (HIB)

Correct Answer: 4

Rationale 1: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella (Var) is given at 12–18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4–8 weeks apart.

Rationale 2: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella (Var) is given at 12–18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4–8 weeks apart.

Rationale 3: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella (Var) is given at 12–18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4–8 weeks apart.

Rationale 4: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella (Var) is given at 12–18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4–8 weeks apart.

Global Rationale: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella (Var) is given at 12–18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4–8 weeks apart.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.4 Plan the nursing care for children of all ages needing immunizations.

 

Question 4

Type: MCSA

A mother refuses to have her child be immunized with 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. Which response by the nurse is most appropriate?

  1. Honor her request because she is the parent.
  2. Explain that antibodies can fight many diseases.
  3. Tell her that not immunizing her infant may protect pregnant women.
  4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

Correct Answer: 4

Rationale 1: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother’s belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Rationale 2: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother’s belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Rationale 3: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother’s belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

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 because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother’s belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Global Rationale: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother’s belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.3 Examine the role that vaccines play in reducing and eliminating communicable diseases.

 

Question 5

Type: MCSA

A parent reports that her school-age 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. Which disease process does the nurse suspect based on the parent’s description?

  1. Chicken pox (varicella)
  2. German measles (rubella)
  3. Roseola (exanthem subitum)
  4. Fifth disease (erythema infectiosum)

Correct Answer: 4

Rationale 1: Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Rationale 2: Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Rationale 3: Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Rationale 4: Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Global Rationale: Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 16.6 Recognize common infectious and communicable diseases.

 

Question 6

Type: MCSA

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site?

  1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.
  2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal.
  3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid.
  4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh.

Correct Answer: 1

Rationale 1: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Rationale 2: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Rationale 3: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

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- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Global Rationale: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 16.4 Plan the nursing care for children of all ages needing immunizations.

 

Question 7

Type: MCSA

Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. What will the school nurse teach families regarding immunizations in order to reach this goal?

  1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020.
  2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease.
  3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases.
  4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.

Correct Answer: 4

Rationale 1: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Rationale 2: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Rationale 3: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Rationale 4: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Global Rationale: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.3 Examine the role that vaccines play in reducing and eliminating communicable diseases.

 

Question 8

Type: MCSA

A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth × 10 days for otitis media. Which teaching point will guard against antibiotic resistance to the disease process?

  1. Administer a loading dose for the first dose.
  2. Measure the prescribed dose in a household teaspoon.
  3. Give the antibiotic for the full 10 days.
  4. Stop the antibiotic if the child is afebrile.

Correct Answer: 3

Rationale 1: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Rationale 2: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Rationale 3: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Rationale 4: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Global Rationale: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.2 Propose strategies to control the spread of infection in healthcare and community settings.

 

Question 9

Type: MCSA

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented?

  1. It is important to separate clients according to age and illness to prevent the spread of disease.”
  2. It is important to dispose blood-contaminated needles in the lead-lined container.”
  3. I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room.”
  4. I will initiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).”

Correct Answer: 3

Rationale 1: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Rationale 2: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Rationale 3: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Rationale 4: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Global Rationale: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.7 Develop a nursing care plan for the child with a common communicable disease.

 

Question 10

Type: MCMA

The school nurse is trying to prevent the spread of a flu virus through the school. Which infection-control strategies can be employed to prevent the spread of the flu virus?

Standard Text: Select all that apply.

  1. Teaching parents safe food preparation and storage
  2. Withholding immunizations for children with compromised immune systems
  3. Sanitizing toys, telephones, and door knobs to kill pathogens
  4. Separating children with infections from children who are well
  5. Teaching children to wash their hands after using the bathroom

Correct Answer: 3,4,5

Rationale 1: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 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. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 2: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 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. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 3: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 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. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 4: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 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. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 5: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 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. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Global Rationale: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 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. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.2 Propose strategies to control the spread of infection in healthcare and community settings.

 

Question 11

Type: MCMA

The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately?

Standard Text: Select all that apply.

  1. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F)
  2. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F)
  3. Child difficult to awaken and has a pulsing fontanel
  4. Child has purple spots on the skin and is lethargic.
  5. Child has a stiff neck and has been irritable for three days.

Correct Answer: 2,3,4,5

Rationale 1: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 2: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 3: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 4: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 5: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Global Rationale: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.6 Recognize common infectious and communicable diseases.

 

Question 12

Type: MCSA

The hospital admitting nurse is taking a history of a child’s illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media. Which action by the parents brought the nurse to this conclusion?

  1. Used aspirin every four hours to reduce the fever
  2. Alternated acetaminophen with ibuprofen every two hours
  3. Put the child in a tub of cold water to reduce the fever
  4. Offered generous amounts of fluids frequently

Correct Answer: 4

Rationale 1: The body’s need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child’s weight, not age. 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: The body’s need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child’s weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Rationale 3: The body’s need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child’s weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Rationale 4: The body’s need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child’s weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Global Rationale: The body’s need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child’s weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 16.7 Develop a nursing care plan for the child with a common communicable disease.

 

Question 13

Type: MCSA

A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the infant was exposed to a brother who has the flu. Which action by the nurse is most appropriate based on these assessment findings?

  1. Withhold the vaccinations.
  2. Give the vaccinations as scheduled.
  3. Withhold the DTaP vaccination but give the others as scheduled.
  4. Give the infant the flu vaccination but withhold the others.

Correct Answer: 2

Rationale 1: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Rationale 2: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Rationale 3: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Rationale 4: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Global Rationale: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.4 Plan the nursing care for children of all ages needing immunizations.

 

Question 14

Type: MCSA

A parent brings her school-age child to the clinic because the child has a temperature of 100.2°F. The child remains active without other symptoms. Which statement by the nurse to the parents is most appropriate?

  1. “Take the child’s temperature every 2 hours and call the clinic if it reaches 102°F or above.”
  2. “Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection.”
  3. “Keep the child warm, because shivering often occurs with fever.”
  4. “Alternate acetaminophen and ibuprofen to help keep the fever down and keep the child comfortable.”

Correct Answer: 2

Rationale 1: Fever is the body’s response to an infection, and is not a disease. Allowing the body’s natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the child’s temperature more than every 4–6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Rationale 2: Fever is the body’s response to an infection, and is not a disease. Allowing the body’s natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the child’s temperature more than every 4–6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Rationale 3: Fever is the body’s response to an infection, and is not a disease. Allowing the body’s natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the child’s temperature more than every 4–6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Rationale 4: Fever is the body’s response to an infection, and is not a disease. Allowing the body’s natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the child’s temperature more than every 4–6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Global Rationale: Fever is the body’s response to an infection, and is not a disease. Allowing the body’s natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the child’s temperature more than every 4–6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.2 Propose strategies to control the spread of infection in healthcare and community settings.

 

Question 15

Type: MCMA

A child is admitted with a diagnosis of early localized Lyme disease. Which clinical manifestations would the nurse expect to find on the initial assessment of this client?

Standard Text: Select all that apply.

  1. Erythema 5–15 cm in diameter
  2. Hyperactivity
  3. Cranial nerve palsies
  4. Fever
  5. Headache

Correct Answer: 1,4,5

Rationale 1: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 2: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 3: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 4: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 5: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Global Rationale: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.6 Recognize common infectious and communicable diseases.

 

 

Question 16

Type: MCMA

 

A nurse working in a pediatric clinic is responsible for monitoring and maintaining the vaccinations on site. Which actions are appropriate for this nurse to implement?

Standard Text: Select all that apply.

  1. Fluctuate refrigerator and freezer temperatures each day.
  2. Store vaccines in the center of the unit.
  3. Check and record the temperature of the unit twice each day.
  4. Have a plan for power outages.
  5. Place bottles of water in each unit to help keep temperatures consistent.

 

Correct Answer: 2,3,4,5

Rationale 1: Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

Rationale 2: Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

Rationale 3: Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

Rationale 4: Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

Rationale 5: Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

Global Rationale: Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 16.5 Outline a plan to maintain the potency of vaccines.

 

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 24

Question 1

Type: MCSA

A child diagnosed with a Wilms tumor is prescribed chemotherapy. Which laboratory test will the nurse monitor prior to administering the chemotherapy to determine the child’s infection-fighting capability?

  1. Hemoglobin
  2. Red-blood-cell count
  3. Absolute neutrophil count (ANC)
  4. Platelets

Correct Answer: 3

Rationale 1: The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body’s infection-fighting capability. Red-blood-cell count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

Rationale 2: The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body’s infection-fighting capability. Red-blood-cell count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

Rationale 3: The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body’s infection-fighting capability. Red-blood-cell count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

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. Red-blood-cell count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

Global Rationale: The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body’s infection-fighting capability. Red-blood-cell count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

 

Question 2

Type: MCSA

A child diagnosed with cancer is prescribed chemotherapy. The latest lab value indicates the white-blood-cell count is very low. Which medication order does the nurse anticipate?

  1. Filgrastim (Neupogen)
  2. Ondansetron (Zofran)
  3. Oprelvekin (Neumega)
  4. Epoetin alfa (human recombinant erythropoietin)

Correct Answer: 1

Rationale 1: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow. Ondansetron (Zofran) is an antiemetic, oprelvekin (Neumega) increases platelets, and epoetin alfa (human recombinant erythropoietin) stimulates red-blood-cell (RBC) production.

Rationale 2: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow. Ondansetron (Zofran) is an antiemetic, oprelvekin (Neumega) increases platelets, and epoetin alfa (human recombinant erythropoietin) stimulates red-blood-cell (RBC) production.

Rationale 3: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow. Ondansetron (Zofran) is an antiemetic, oprelvekin (Neumega) increases platelets, and epoetin alfa (human recombinant erythropoietin) stimulates red-blood-cell (RBC) production.

Rationale 4: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow. Ondansetron (Zofran) is an antiemetic, oprelvekin (Neumega) increases platelets, and epoetin alfa (human recombinant erythropoietin) stimulates red-blood-cell (RBC) production.

Global Rationale: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow. Ondansetron (Zofran) is an antiemetic, oprelvekin (Neumega) increases platelets, and epoetin alfa (human recombinant erythropoietin) stimulates red-blood-cell (RBC) production.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 24.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

 

Question 3

Type: MCSA

A preschool child is seen in the clinic, and the nurse anticipates a diagnosis of leukemia. Which reaction does the nurse anticipate this child will exhibit upon diagnosis?

  1. Acceptance, especially if able to discuss the disease with children their own age
  2. Thoughts that they caused their illness and are being punished
  3. Understanding of what cancer is and how it is treated
  4. Unawareness of the illness and its severity

Correct Answer: 2

Rationale 1: Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

Rationale 2: Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

Rationale 3: Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

Rationale 4: Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

Global Rationale: Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

 

Question 4

Type: MCSA

The nurse is monitoring the urine specific gravity and pH on a child receiving chemotherapy. Which urinalysis result is the goal for this child?

  1. Spec gravity 1.030; pH 6
  2. Spec gravity 1.030; pH 7.5
  3. Spec gravity 1.005; pH 6
  4. Spec gravity 1.005; pH 7.5

Correct Answer: 4

Rationale 1: Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the urine specific gravity should remain at less than 1.010 and the pH at 7 to 7.5. 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 2: Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the urine specific gravity should remain at less than 1.010 and the pH at 7 to 7.5. 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 3: Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the urine specific gravity should remain at less than 1.010 and the pH at 7 to 7.5. 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 urine specific gravity should remain at less than 1.010 and the pH at 7 to 7.5. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis.

Global Rationale: Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the urine specific gravity should remain at less than 1.010 and the pH at 7 to 7.5. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

 

Question 5

Type: MCSA

The antiemetic drug ondansetron (Zofran) is administered to a child receiving chemotherapy. When should the nurse administer this medication?

  1. Only if the child experiences nausea
  2. After the chemotherapy has been administered
  3. Before chemotherapy administration as a prophylactic measure
  4. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.

Correct Answer: 3

Rationale 1: The antiemetic ondansetron (Zofran) should be administered before chemotherapy as a prophylactic measure. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea. It is the drug of choice for controlling nausea caused by chemotherapy agents.

Rationale 2: The antiemetic ondansetron (Zofran) should be administered before chemotherapy as a prophylactic measure. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea. It is the drug of choice for controlling nausea caused by chemotherapy agents.

Rationale 3: The antiemetic ondansetron (Zofran) should be administered before chemotherapy as a prophylactic measure. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea. It is the drug of choice for controlling nausea caused by chemotherapy agents.

Rationale 4: The antiemetic ondansetron (Zofran) should be administered before chemotherapy as a prophylactic measure. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea. It is the drug of choice for controlling nausea caused by chemotherapy agents.

Global Rationale: The antiemetic ondansetron (Zofran) should be administered before chemotherapy as a prophylactic measure. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea. It is the drug of choice for controlling nausea caused by chemotherapy agents.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 24.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

 

Question 6

Type: MCSA

A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is the most appropriate?

  1. Administer intramuscular injections (IM).
  2. Perform oral hygiene.
  3. Monitor intake and output.
  4. Use palpation as a component of assessment.

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. Oral hygiene care should be done with a soft toothbrush and intake and output monitored for any abnormalities. Gentle palpation should still be included in physical assessments.

Rationale 2: When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections because of the risk of bleeding. Oral hygiene care should be done with a soft toothbrush and intake and output monitored for any abnormalities. Gentle palpation should still be included in physical assessments.

Rationale 3: When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections because of the risk of bleeding. Oral hygiene care should be done with a soft toothbrush and intake and output monitored for any abnormalities. Gentle palpation should still be included in physical assessments.

Rationale 4: When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections because of the risk of bleeding. Oral hygiene care should be done with a soft toothbrush and intake and output monitored for any abnormalities. Gentle palpation should still be included in physical assessments.

Global Rationale: When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections because of the risk of bleeding. Oral hygiene care should be done with a soft toothbrush and intake and output monitored for any abnormalities. Gentle palpation should still be included in physical assessments.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

 

Question 7

Type: SEQ

A child undergoing chemotherapeutic treatment for cancer is being admitted to the hospital for fever of 102 degrees F and possible sepsis. Cultures, antibiotics, and acetaminophen (Tylenol) along with bed rest have been ordered for this child. Place the following steps in order from first to last.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Administer the antibiotics.

Response 2. Administer the acetaminophen (Tylenol).

Response 3. Obtain the cultures.

Response 4. Ensure the child has bed rest.

Correct Answer: 2,3,1,4

Rationale 1: Give acetaminophen (Tylenol) first to decrease discomfort and reduce fever. Obtain the cultures next because management of infections is critical, and since a child on chemotherapy has lowered immune status, unusual agents can be identified. Cultures can help identify the causative agents before treatment is started. Give the antibiotics next, as an infection can seriously impact the child who is receiving chemotherapy. Finally, provide comfort followed by bed rest to allow the child to rest.

Rationale 2: Give acetaminophen (Tylenol) first to decrease discomfort and reduce fever. Obtain the cultures next because management of infections is critical, and since a child on chemotherapy has lowered immune status, unusual agents can be identified. Cultures can help identify the causative agents before treatment is started. Give the antibiotics next, as an infection can seriously impact the child who is receiving chemotherapy. Finally, provide comfort followed by bed rest to allow the child to rest.

Rationale 3: Give acetaminophen (Tylenol) first to decrease discomfort and reduce fever. Obtain the cultures next because management of infections is critical, and since a child on chemotherapy has lowered immune status, unusual agents can be identified. Cultures can help identify the causative agents before treatment is started. Give the antibiotics next, as an infection can seriously impact the child who is receiving chemotherapy. Finally, provide comfort followed by bed rest to allow the child to rest.

Rationale 4: Give acetaminophen (Tylenol) first to decrease discomfort and reduce fever. Obtain the cultures next because management of infections is critical, and since a child on chemotherapy has lowered immune status, unusual agents can be identified. Cultures can help identify the causative agents before treatment is started. Give the antibiotics next, as an infection can seriously impact the child who is receiving chemotherapy. Finally, provide comfort followed by bed rest to allow the child to rest.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 24.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

 

Question 8

Type: MCSA

A 24-hour urine collection for vanillylmandelic acid (VMA) has been ordered on a child suspected of having neuroblastoma. When is the most appropriate time for the nurse to begin the collection?

  1. At 0700
  2. After the next time the child voids
  3. At bedtime
  4. When the order is noted

Correct Answer: 2

Rationale 1: A 24-hour urine collection is started after the child voids. That specimen is not saved, but all subsequent specimens in that 24-hour period should be collected. It would not be an accurate collection of 24 hours of urine if the collection began at 0700, bedtime, or when the order is noted.

Rationale 2: A 24-hour urine collection is started after the child voids. That specimen is not saved, but all subsequent specimens in that 24-hour period should be collected. It would not be an accurate collection of 24 hours of urine if the collection began at 0700, bedtime, or when the order is noted.

Rationale 3: A 24-hour urine collection is started after the child voids. That specimen is not saved, but all subsequent specimens in that 24-hour period should be collected. It would not be an accurate collection of 24 hours of urine if the collection began at 0700, bedtime, or when the order is noted.

Rationale 4: A 24-hour urine collection is started after the child voids. That specimen is not saved, but all subsequent specimens in that 24-hour period should be collected. It would not be an accurate collection of 24 hours of urine if the collection began at 0700, bedtime, or when the order is noted.

Global Rationale: A 24-hour urine collection is started after the child voids. That specimen is not saved, but all subsequent specimens in that 24-hour period should be collected. It would not be an accurate collection of 24 hours of urine if the collection began at 0700, bedtime, or when the order is noted.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 24.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

 

Question 9

Type: MCSA

A child is diagnosed with a Wilms tumor. Which nursing action is most appropriate prior to surgery?

  1. Careful bathing and handling
  2. Monitoring of behavioral status
  3. Maintenance of strict isolation
  4. Administration of packed red-blood cells

Correct Answer: 1

Rationale 1: The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child’s behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed red-blood cells is not usually a nursing intervention.

Rationale 2: The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child’s behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed red-blood cells is not usually a nursing intervention.

Rationale 3: The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child’s behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed red-blood cells is not usually a nursing intervention.

Rationale 4: The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child’s behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed red-blood cells is not usually a nursing intervention.

Global Rationale: The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child’s behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed red-blood cells is not usually a nursing intervention.

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 24.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

 

Question 10

Type: MCSA

An adolescent is receiving methotrexate chemotherapy after undergoing limb-salvage surgery for osteogenic sarcoma. Which statement by the adolescent indicates understanding of the purpose of leucovorin therapy after the methotrexate?

  1. “I’m glad I only need one dose of the leucovorin.”
  2. “I don’t have any pain so I won’t need to take the leucovorin this time.”
  3. “I know I will be taking the leucovorin every 6 hours for about the next 3 days.”
  4. “I don’t have any nausea so I won’t need the leucovorin.”

Correct Answer: 3

Rationale 1: 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 6 hours for 72 hours or until serum methotrexate is at the desired level.

Rationale 2: 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 6 hours for 72 hours or until serum methotrexate is at the desired level.

Rationale 3: Leucovorin (citrovorum factor) is a form of folic acid that helps to protect normal cells from the destructive action of methotrexate. It is started within 24 hours of methotrexate administration and is given along with hydration therapy. Usual administration is every 6 hours for 72 hours or until serum methotrexate is at the desired level.

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 6 hours for 72 hours or until serum methotrexate is at the desired level.

Global Rationale: 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 6 hours for 72 hours or until serum methotrexate is at the desired level.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 24.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

 

Question 11

Type: MCSA

A child who is diagnosed with leukemia has a sibling who is expressing feelings of anger and guilt. How would the nurse characterize this reaction by the sibling?

  1. Abnormal; the sibling should be referred to a psychologist.
  2. Normal; the illness doesn’t affect the sibling.
  3. Unexpected; the cancer is easily treated.
  4. Normal; the sibling is affected too, and anger and guilt are expected feelings.

Correct Answer: 4

Rationale 1: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal.

Rationale 2: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal.

Rationale 3: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal.

Rationale 4: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal.

Global Rationale: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

 

Question 12

Type: MCSA

The child is admitted to the hospital after being diagnosed with retinoblastoma. Which assessment finding does the nurse anticipate for this child?

  1. A red reflex
  2. Yellow sclera
  3. A white pupil
  4. Blue-tinged sclera

Correct Answer: 3

Rationale 1: The first sign of retinoblastoma is a white pupil. The red reflex is absent. Yellow sclera is a sign of jaundice, not retinoblastoma. Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

Rationale 2: The first sign of retinoblastoma is a white pupil. The red reflex is absent. Yellow sclera is a sign of jaundice, not retinoblastoma. Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

Rationale 3: The first sign of retinoblastoma is a white pupil. The red reflex is absent. Yellow sclera is a sign of jaundice, not retinoblastoma. Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

Rationale 4: The first sign of retinoblastoma is a white pupil. The red reflex is absent. Yellow sclera is a sign of jaundice, not retinoblastoma. Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

Global Rationale: first sign of retinoblastoma is a white pupil. The red reflex is absent. Yellow sclera is a sign of jaundice, not retinoblastoma. Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

 

Question 13

Type: MCSA

A preschool-age child is brought to the clinic by the mother, who says the child has been lethargic and anorexic lately and complains of bone pain. On exam, the nurse notes petechiae, joint pain, and an enlarged liver. Which diagnosis does the nurse anticipate for this child?

  1. Hodgkin disease
  2. Leukemia
  3. Rhabdomyosarcoma
  4. Ewing sarcoma

Correct Answer: 2

Rationale 1: Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

Rationale 2: Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

Rationale 3: Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

Rationale 4: Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

Global Rationale: Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

 

Question 14

Type: MCSA

A child with a brain tumor is admitted to the pediatric intensive care unit (PICU)after brain surgery to remove the tumor. Which postoperative order would the nurse question?

  1. Antibiotics
  2. Sodium levels every 24 hours
  3. Anticonvulsants
  4. Hourly intake and output

Correct Answer: 2

Rationale 1: Antibiotics, anticonvulsants, and hourly intake and output are appropriate orders. Serum sodium levels should be done every 4–6 hours, not every 24 hours.

Rationale 2: Antibiotics, anticonvulsants, and hourly intake and output are appropriate orders. Serum sodium levels should be done every 4–6 hours, not every 24 hours.

Rationale 3: Antibiotics, anticonvulsants, and hourly intake and output are appropriate orders. Serum sodium levels should be done every 4–6 hours, not every 24 hours.

Rationale 4: Antibiotics, anticonvulsants, and hourly intake and output are appropriate orders. Serum sodium levels should be done every 4–6 hours, not every 24 hours.

Global Rationale: Antibiotics, anticonvulsants, and hourly intake and output are appropriate orders. Serum sodium levels should be done every 4–6 hours, not every 24 hours.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

 

Question 15

Type: MCSA

A child is diagnosed with rhabdomyosarcoma. Which nursing intervention is most appropriate for this child?

  1. Position the child with the head elevated.
  2. Monitor for hematuria.
  3. Demonstrate the use of a conformer.
  4. Administer oxygen.

Correct Answer: 1

Rationale 1: The most common area of the body affected by rhabdomyosarcoma is the bladder. The nursing intervention that is most appropriate is to monitor the child’s urine for hematuria. Positioning the child with the head elevated and administering oxygen is appropriate for a child diagnosed with lymphoma. Demonstrating the use of a conformer is appropriate for a child diagnosed with retinoblastoma.

Rationale 2: The most common area of the body affected by rhabdomyosarcoma is the bladder. The nursing intervention that is most appropriate is to monitor the child’s urine for hematuria. Positioning the child with the head elevated and administering oxygen is appropriate for a child diagnosed with lymphoma. Demonstrating the use of a conformer is appropriate for a child diagnosed with retinoblastoma.

Rationale 3: The most common area of the body affected by rhabdomyosarcoma is the bladder. The nursing intervention that is most appropriate is to monitor the child’s urine for hematuria. Positioning the child with the head elevated and administering oxygen is appropriate for a child diagnosed with lymphoma. Demonstrating the use of a conformer is appropriate for a child diagnosed with retinoblastoma.

Rationale 4: The most common area of the body affected by rhabdomyosarcoma is the bladder. The nursing intervention that is most appropriate is to monitor the child’s urine for hematuria. Positioning the child with the head elevated and administering oxygen is appropriate for a child diagnosed with lymphoma. Demonstrating the use of a conformer is appropriate for a child diagnosed with retinoblastoma.

Global Rationale: The most common area of the body affected by rhabdomyosarcoma is the bladder. The nursing intervention that is most appropriate is to monitor the child’s urine for hematuria. Positioning the child with the head elevated and administering oxygen is appropriate for a child diagnosed with lymphoma. Demonstrating the use of a conformer is appropriate for a child diagnosed with retinoblastoma.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.6 Prioritize elements of comprehensive care planning for children with soft-tissue tumors.

 

Question 16

Type: MCMA

 

The pediatric nurse educator is conducting an in-service for novice nurses who will begin working on the pediatric oncology unit. The educator wants to include the common clinical manifestations of cancer. Which manifestation will the educator include in the presentation?

Standard Text: Select all that apply.

  1. Cachexia
  2. Anemia
  3. Gene abnormalities
  4. Palpable mass
  5. Chromosomal abnormalities

Correct Answer: 1,2,4

Rationale 1: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

Rationale 2: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

Rationale 3: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

Rationale 4: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

Rationale 5: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

Global Rationale: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 24.1 Describe the incidence, known etiologies, and common clinical manifestations of cancer.

 

Question 17

Type: MCMA

 

The pediatric nurse is providing care to a school-age child receiving chemotherapy to treat cancer. Which interventions are appropriate to include in the plan of care in order to monitor for oncologic emergencies?

Standard Text: Select all that apply.

  1. Monitor complete blood count (CBC).
  2. Document intake and output.
  3. Observe for behavioral changes.
  4. Refer for psychosocial support.
  5. Implement neutropenic precautions.

Correct Answer: 1,2,3

Rationale 1: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

 

Rationale 2: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

 

Rationale 3: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

 

Rationale 4: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

 

Rationale 5: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

 

Global Rationale: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

 

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 24.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

 

Question 18

Type: MCMA

 

A seasoned nurse is precepting a novice nurse on a pediatric oncology unit. The seasoned nurse would like to review the ongoing physiologic and psychosocial care of the children who survive cancer. Which topics will the seasoned nurse include in the discussion with the novice nurse?

Standard Text: Select all that apply.

  1. Developing other cancers
  2. Recommending regular office visits
  3. Encouraging school-age clients to manage their own care
  4. Needing weekly laboratory tests
  5. Providing educational and psychosocial support

Correct Answer: 1,2,5

Rationale 1: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support.  It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

Rationale 2: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support.  It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

Rationale 3: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support.  It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

Rationale 4: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support.  It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

Rationale 5: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support.  It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

Global Rationale: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support.  It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 24.7 Analyze the impact of cancer survival on children and use this information to plan for ongoing physiologic and psychosocial care in the children’s futures.

 

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 30

Question 1

Type: MCSA

A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis?

  1. Hyperglycemia
  2. Hypernatremia
  3. Hypercalcemia
  4. Hypoglycemia

Correct Answer: 2

Rationale 1: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Rationale 2: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Rationale 3: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Rationale 4: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Global Rationale: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.3 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

Question 2

Type: MCSA

A nurse is conducting a daily weight on a pediatric client diagnosed with diabetes insipidus and notes the child has lost two pounds in 24 hours. Which action by the nurse is the most appropriate?

  1. Continue to monitor the child.
  2. Notify the healthcare provider regarding the weight loss.
  3. Chart the weight and report the loss to the next shift.
  4. Do nothing more than chart the weight, as this would be a normal finding.

Correct Answer: 2

Rationale 1: With diabetes insipidus, the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the healthcare provider should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Rationale 2: With diabetes insipidus, the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the healthcare provider should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Rationale 3: With diabetes insipidus, the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the healthcare provider should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Rationale 4: With diabetes insipidus, the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the healthcare provider should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Global Rationale: With diabetes insipidus, the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the healthcare provider should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.5 Prioritize nursing care for each type of acquired metabolic disorder.

 

Question 3

Type: MCMA

The nurse is caring for a pediatric client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) disorder. Which interventions should the nurse implement for this child?

Standard Text: Select all that apply.

  1. Encouragement of fluids
  2. Strict intake and output
  3. Administration of ordered diuretics
  4. Specific gravity of urine
  5. Weight only on admission but not daily

Correct Answer: 2,3,4

Rationale 1: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 2: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 3: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 4: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 5: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Global Rationale: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 30.5 Prioritize nursing care for each type of acquired metabolic disorder.

 

Question 4

Type: MCSA

An adolescent client diagnosed with Graves disease is admitted to the hospital. Which clinical manifestations would the nurse expect on assessment?

  1. Weight gain, hirsutism, and muscle weakness
  2. Dehydration, metabolic acidosis, and hypertension
  3. Tachycardia, fatigue, and heat intolerance
  4. Hyperglycemia, ketonuria, and glucosuria

Correct Answer: 3

Rationale 1: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 2: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 3: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 4: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Global Rationale: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Phyiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.3 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

 

Question 5

Type: MCSA

A nurse is planning care for a pediatric client diagnosed with adrenal insufficiency (Addison disease). Which nursing diagnosis is the priority for this client?

  1. Risk for Deficient Fluid Volume
  2. Risk for Injury Secondary to Hypertension
  3. Acute Pain
  4. Imbalanced Nutrition: More than Body Requirements

Correct Answer: 1

Rationale 1: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Rationale 2: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Rationale 3: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Rationale 4: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Global Rationale: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 30.5 Prioritize nursing care for each type of acquired metabolic disorder.

 

Question 6

Type: MCSA

A pediatric client is admitted to the hospital unconscious. The client has a history of type 1 diabetes, and according to the client’s mother, has been to two birthday parties in the last few days and has resisted taking the prescribed insulin. At school the client had two more pieces of birthday cake and some ice cream at a class birthday party. What is the likely reason for this client’s unconscious state?

  1. Metabolic alkalosis
  2. Metabolic ketoacidosis
  3. Insulin shock
  4. Insulin reaction

Correct Answer: 2

Rationale 1: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Rationale 2: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Rationale 3: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Rationale 4: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Global Rationale: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.7 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

 

Question 7

Type: MCSA

A pediatric client is diagnosed with type 1 diabetes. The nurse teaches the client the difference between insulin shock and diabetic hyperglycemia. The nurse evaluates that the client understands the teaching when the client states which characteristics of diabetic hyperglycemia?

  1. Tremors and lethargy
  2. Hunger and hypertension
  3. Thirst and flushed skin
  4. Shakiness and pallor

Correct Answer: 3

Rationale 1: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Rationale 2: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Rationale 3: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Rationale 4: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Global Rationale: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.7 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

 

Question 8

Type: MCSA

The nurse is providing education to a pediatric client diagnosed with diabetes. The client will be playing soccer over the summer. Which change in the client’s management will the nurse explore during this education session?

  1. Increased food intake
  2. Decreased food intake
  3. Increased need for insulin
  4. Decreased risk of insulin reaction

Correct Answer: 1

Rationale 1: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Rationale 2: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Rationale 3: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Rationale 4: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Global Rationale: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 30.7 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

 

Question 9

Type: MCSA

The nurse is teaching the parent of a type 1 diabetic preschool-age client about management of the disease. Which teaching point is appropriate for the nurse to include in this session?

  1. Allowing the client to administer all the insulin injections
  2. Allowing the client to choose which finger to stick for glucose testing
  3. Allowing the client to draw up the insulin dose
  4. Allowing the client to test blood glucose

Correct Answer: 2

Rationale 1: The preschool-age client’s need for autonomy and control can be met by allowing the client to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the client until he or she is middle-school age or older.

Rationale 2: The preschool-age client’s need for autonomy and control can be met by allowing the client to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the client until he or she is middle-school age or older.

Rationale 3: The preschool-age client’s need for autonomy and control can be met by allowing the client to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the client until he or she is middle-school age or older.

Rationale 4: The preschool-age client’s need for autonomy and control can be met by allowing the client to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the client until he or she is middle-school age or older.

Global Rationale: The preschool-age client’s need for autonomy and control can be met by allowing the client to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the client until he or she is middle-school age or older.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 30.7 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

 

Question 10

Type: MCSA

A pediatric client is seen in the clinic with a possible diagnosis of type 2 diabetes. The mother asks what the healthcare provider uses to make the diagnosis. The nurse explains that type 2 diabetes is suspected if the child has obesity, acanthosis nigricans, and two non-fasting blood-glucose levels above which level?

  1. 120
  2. 80
  3. 200
  4. 50

Correct Answer: 3

Rationale 1: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of type 2 diabetes.

Rationale 2: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of type 2 diabetes.

Rationale 3: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of type 2 diabetes.

Rationale 4: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of type 2 diabetes.

Global Rationale: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of type 2 diabetes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.3 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

 

Question 11

Type: MCSA

A pediatric client diagnosed with Turner syndrome tells the nurse, “I feel different from my peers.” Which response by the nurse is the most appropriate?

  1. “Tell me more about the feelings you are experiencing.”
  2. “These feelings are not unusual and should pass soon.”
  3. “You’ll start to grow soon, so don’t worry.”
  4. “You seem to be upset about your disease.”

Correct Answer: 1

Rationale 1: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girl’s perception of her body and how she differs from peers. The nurse should encourage more expression of the girl’s feelings. Responding that the feelings will pass, that she’ll start to grow, or that she is upset about the disease would not be therapeutic.

Rationale 2: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girl’s perception of her body and how she differs from peers. The nurse should encourage more expression of the girl’s feelings. Responding that the feelings will pass, that she’ll start to grow, or that she is upset about the disease would not be therapeutic.

Rationale 3: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girl’s perception of her body and how she differs from peers. The nurse should encourage more expression of the girl’s feelings. Responding that the feelings will pass, that she’ll start to grow, or that she is upset about the disease would not be therapeutic.

Rationale 4: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girl’s perception of her body and how she differs from peers. The nurse should encourage more expression of the girl’s feelings. Responding that the feelings will pass, that she’ll start to grow, or that she is upset about the disease would not be therapeutic.

Global Rationale: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girl’s perception of her body and how she differs from peers. The nurse should encourage more expression of the girl’s feelings. Responding that the feelings will pass, that she’ll start to grow, or that she is upset about the disease would not be therapeutic.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 30.8 Plan care for the child with an inherited metabolic disorder.

 

Question 12

Type: MCSA

A parent of a newborn asks the nurse why a heel stick is being done on the baby to test for phenylketonuria (PKU). Which response by the nurse is the most appropriate?

  1. “This screening is required and detection can be done before symptoms develop.”
  2. “The infant has high-risk characteristics.”
  3. “Because the infant was born by cesarean, this test is necessary.”
  4. “Because the infant was born by vaginal delivery, this test is recommended.”

Correct Answer: 1

Rationale 1: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Rationale 2: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Rationale 3: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Rationale 4: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Global Rationale: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 30.3 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

 

Question 13

Type: MCSA

The nurse is administering a dose of rapid-acting insulin at 0800 to an insulin-dependent pediatric client. Based on when the insulin peaks, when will the client be at greatest risk for a hypoglycemic episode?

  1. At about noon
  2. Between bedtime and breakfast the next morning
  3. Between lunch and dinner
  4. Around 0930

Correct Answer: 4

Rationale 1: Rapid-acting insulin peaks 30–90 minutes after administration. An injection given at 0800 would peak around 0930.

Rationale 2: Rapid-acting insulin peaks 30–90 minutes after administration. An injection given at 0800 would peak around 0930.

Rationale 3: Rapid-acting insulin peaks 30–90 minutes after administration. An injection given at 0800 would peak around 0930.

Rationale 4: Rapid-acting insulin peaks 30–90 minutes after administration. An injection given at 0800 would peak around 0930.

Global Rationale: Rapid-acting insulin peaks 30–90 minutes after administration. An injection given at 0800 would peak around 0930.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 30.7 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

 

Question 14

Type: MCMA

Which teaching tips should be included when instructing parents on hydrocortisone administration?

Standard Text: Select all that apply.

  1. Maintain prescribed administration times.
  2. Never discontinue medication abruptly.
  3. Injections might be necessary when unable to take by mouth.
  4. Lower doses are needed during illness.
  5. Keep an emergency kit with the child at all times.

Correct Answer: 1,2,3,5

Rationale 1: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 2: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 3: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 4: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 5: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Global Rationale: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 30.6 Develop a family education plan for the child who needs lifelong cortisol replacement.

 

Question 15

Type: MCSA

The nurse is planning care for a pediatric client diagnosed with adrenal hyperplasia. Which nursing diagnosis is most appropriate for this client?

  1. Impaired Social Interaction Related to Unnatural Facial Features
  2. Nutrition: Less than Body Requirements due to Nausea and Vomiting
  3. Depression Related to Inability to Take in Oral Fluids
  4. Risk for Deficient Fluid Volume Related to Failure of Regulatory Mechanisms

Correct Answer: 4

Rationale 1: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Rationale 2: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Rationale 3: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Rationale 4: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Global Rationale: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 30.8 Plan care for the child with an inherited metabolic disorder.

 

Question 16

Type: MCMA

 

The nurse is planning care for pediatric clients who have diagnoses that impact the endocrine system. Which changes occurring during the school-age and adolescence have a direct impact on the endocrine system?

Standard Text: Select all that apply.

  1. Puberty
  2. Adrenarche
  3. Menarche
  4. Sexual exploration
  5. Risk-taking behavior

Correct Answer: 1,2,3

Rationale 1: Puberty, adrenarche, and menarche are all changes that occur during the school age and adolescence that have a direct impact on the endocrine system. Sexual exploration and risk-taking behaviors do not have a direct impact on the endocrine system.

Rationale 2: Puberty, adrenarche, and menarche are all changes that occur during the school age and adolescence that have a direct impact on the endocrine system. Sexual exploration and risk-taking behaviors do not have a direct impact on the endocrine system.

Rationale 3: Puberty, adrenarche, and menarche are all changes that occur during the school age and adolescence that have a direct impact on the endocrine system. Sexual exploration and risktaking behaviors do not have a direct impact on the endocrine system.

Rationale 4: Puberty, adrenarche, and menarche are all changes that occur during the school age and adolescence that have a direct impact on the endocrine system. Sexual exploration and risk-taking behaviors do not have a direct impact on the endocrine system.

Rationale 5: Puberty, adrenarche, and menarche are all changes that occur during the school age and adolescence that have a direct impact on the endocrine system. Sexual exploration and risk-taking behaviors do not have a direct impact on the endocrine system.

Global Rationale: Puberty, adrenarche, and menarche are all changes that occur during the school age and adolescence that have a direct impact on the endocrine system. Sexual exploration and risk-taking behaviors do not have a direct impact on the endocrine system.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 30.1 Describe the anatomy and physiology of the endocrine system and pediatric differences.

 

Question 17

Type: MCMA

 

The nurse educator is teaching a group of nursing students about the endocrine system. Which statements are appropriate for the educator to include in the teaching session?

Standard Text: Select all that apply.

  1. Gonadotropin-releasing hormone stimulates the anterior pituitary to produce LH and FSH.
  2. Growth hormone regulates linear bone growth and growth of all tissues.

 

  1. Antidiuretic hormone regulates urine concentration by the kidneys.

 

  1. Thyroid hormone regulates serum calcium levels and phosphorus excretion.

 

  1. Parathyroid hormone regulates metabolism of cells and body heat production.

 

Correct Answer: 1,2,3

 

Rationale 1: All statements are correct except the statements regarding the thyroid hormone and the parathyroid hormone. The thyroid hormone regulates metabolism of the cells and body heat production, not the parathyroid hormone. The parathyroid hormone regulates serum calcium levels and phosphorus excretion.

 

Rationale 2: All statements are correct except the statements regarding the thyroid hormone and the parathyroid hormone. The thyroid hormone regulates metabolism of the cells and body heat production, not the parathyroid hormone. The parathyroid hormone regulates serum calcium levels and phosphorus excretion.

 

Rationale 3: All statements are correct except the statements regarding the thyroid hormone and the parathyroid hormone. The thyroid hormone regulates metabolism of the cells and body heat production, not the parathyroid hormone. The parathyroid hormone regulates serum calcium levels and phosphorus excretion.

 

Rationale 4: All statements are correct except the statements regarding the thyroid hormone and the parathyroid hormone. The thyroid hormone regulates metabolism of the cells and body heat production, not the parathyroid hormone. The parathyroid hormone regulates serum calcium levels and phosphorus excretion.

 

Rationale 5: All statements are correct except the statements regarding the thyroid hormone and the parathyroid hormone. The thyroid hormone regulates metabolism of the cells and body heat production, not the parathyroid hormone. The parathyroid hormone regulates serum calcium levels and phosphorus excretion.

 

Global Rationale: All statements are correct except the statements regarding the thyroid hormone and the parathyroid hormone. The thyroid hormone regulates metabolism of the cells and body heat production, not the parathyroid hormone. The parathyroid hormone regulates serum calcium levels and phosphorus excretion.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 30.2 Identify the function of important hormones of the endocrine system.

 

Question 18

Type: MCMA

 

The nurse is providing education to a group of student nurses regarding disorders of the endocrine system that can cause short stature. Which disorders will the nurse include in the educational session?

Standard Text: Select all that apply.

  1. Hypothyroidism
  2. Turner syndrome
  3. Type 1 diabetes mellitus
  4. Diabetes insipidus
  5. Cushing syndrome

Correct Answer: 1,2,5

Rationale 1: There are many disorders of the endocrine system that can cause short stature including hypothyroidism, Turner syndrome, and Cushing syndrome. Type 1 diabetes mellitus and diabetes insipidus are not endocrine disorders that cause short stature.

Rationale 2: There are many disorders of the endocrine system that can cause short stature including hypothyroidism, Turner syndrome, and Cushing syndrome. Type 1 diabetes mellitus and diabetes insipidus are not endocrine disorders that cause short stature.

Rationale 3: There are many disorders of the endocrine system that can cause short stature including hypothyroidism, Turner syndrome, and Cushing syndrome. Type 1 diabetes mellitus and diabetes insipidus are not endocrine disorders that cause short stature.

Rationale 4: There are many disorders of the endocrine system that can cause short stature including hypothyroidism, Turner syndrome, and Cushing syndrome. Type 1 diabetes mellitus and diabetes insipidus are not endocrine disorders that cause short stature.

Rationale 5: There are many disorders of the endocrine system that can cause short stature including hypothyroidism, Turner syndrome, and Cushing syndrome. Type 1 diabetes mellitus and diabetes insipidus are not endocrine disorders that cause short stature.

Global Rationale: There are many disorders of the endocrine system that can cause short stature including hypothyroidism, Turner syndrome, and Cushing syndrome. Type 1 diabetes mellitus and diabetes insipidus are not endocrine disorders that cause short stature.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 30.4 Identify all conditions for which short stature is a sign.

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