Test Bank For Pediatric Nursing The Critical Components of Nursing Care 1st Edition By Rudd

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Pediatric Nursing The Critical Components of Nursing Care 1st Edition By Rudd

 

Chapter 4: Cultural, Spiritual, and Environmental Influences on the Child

 

 

 

Multiple Choice

 

 

 

  1. Elsa is working with an 11-year-old patient in the outpatient pediatric clinic. As Elsa reviews the chart, she reads that the patient follows the Muslim tradition. When Elsa enters the room, she notes that the child is wearing a hijab on her head. Elsa has never worked with this tradition before. Elsa should:
  2. Realize that her verbal and non-verbal communication will impact the care she gives the child.
  3. Not ask the parent for input on the care of the child because this would disrespect the family and child.
  4. Have another nurse, who has experience with this culture, take care of the patient.
  5. Realize that the patient is uncomfortable and seek a fellow nurse to help her.

 

ANS: 1

  Feedback
1. Verbal and non-verbal communication differs in each culture, thus this must be taken into consideration when working with the child.
2. The lack of communication with the parent and child is not therapeutic for the child.
3. Another nurse may be beneficial, but since Elsa has already started caring for the child, this may create problems.
4. There is no indication of the patient feeling uncomfortable.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A pediatric nursing class has been assigned to use the Giger and Davidhizar Transcultural Assessment Model. The students are assigned to families they do not have a prior relationship with. When performing the assessment, one of the students is given a seat in close proximity to a grandmother on the couch. The student should know that according to this model:
  2. Visiting a family is considered a privilege.
  3. It is important to identify the family lifestyle.
  4. Sitting close to the grandmother can affect the communication.
  5. Only the interpersonal relationships of the individuals are emphasized.

 

ANS: 3

  Feedback
1. Does not address the economic standing of the family
2. Does not identify a “lifestyle”
3. Space is a component of the model.
4. Views the family’s interactions with society

KEY: Content Area: Culture | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A staff educational day has been planned for the pediatric unit of a major hospital. The goal is to make the staff culturally competent. This is important because:
  2. This competency meets JCAHO requirements.
  3. This competency meets cultural care requirements for the hospital system.
  4. This allows nurses to tailor their care to the patient and provide holistic care.
  5. This education is needed to reach Magnet status.

 

ANS: 3

  Feedback
1. Not the purpose of the goal
2. Can be a purpose of the hospital, but does not take precedence over the patient.
3. Important to view the patient holistically in order to provide quality care
4. Not the purpose of the goal

KEY: Content Area: Culture | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Hussain’s parents have a language barrier with the nursing staff on the pediatric floor. When working with communication barriers, it is important to:
  2. Use pictures when an interpreter is not available.
  3. Use hand gestures to attempt to communicate.
  4. Ask the interpreter to speak to the family over the phone.
  5. Require the family to provide a family member to interpret.

 

ANS: 1

  Feedback
1. This is appropriate if there are pictures for the conversation.
2. Each culture is sensitive to body language. Avoid using gestures because this may offend the family.
3. Speaking over the phone can cause communication breakdown, which will not be effective for the conversation.
4. It is a responsibility of the hospital to provide an interpreter for the patient.

KEY: Content Area: Communication | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Social skills between different cultures are important for a pediatric nurse to understand. All of the following are part of social skills except:
  2. Personal space.
  3. Eye contact.
  4. Diet.
  5. Exercise.

ANS: 4

  Feedback
1. Influences social skills of cultures
2. Influences social skills of cultures
3. Influences social skills of cultures
4. Not an influence of social skills of cultures

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The community pediatric nurse is conducting a home visit with a new family. The nurse knows when she is in the home, it will be important to get a thorough assessment. The assessment should consist of:
  2. The number of family members living in the home.
  3. The employment of the adults in the home.
  4. How personal space is perceived.
  5. All of the above should be considered in the assessment.

 

ANS: 4

  Feedback
1. An important component, along with other choices
2. An important component, along with other choices
3. An important component, along with other choices
4. Family members, employment, and personal space should all be assessed by the nurse.

KEY: Content Area: Community/Culture | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Culturally competent care includes:
  2. Treating others exactly how you would like to be treated.
  3. Seeing individuals as unique.
  4. Treating individuals within the same cultural group the same.
  5. Providing care without concern of your own values.

 

ANS: 2

  Feedback
1. This is important to understand the cultural norms and values
2. Cultural competence includes treating individuals as unique beings.
3. Not all cultural groups follow the same norms and values.
4. Realization of personal values enables the nurse to be culturally competent.

KEY: Content Area: Cultural Care | Integrated Processes: Communication/Documentation | Client Need: Teaching/Learning | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A nurse is caring for a 12-year-old patient who has recently been hospitalized. Which statement by the patient proves that the nurse did not perform a complete cultural assessment?
  2. “I’m glad that my prayer times work around my care.”
  3. “I feel better when my mom stays with me.”
  4. “I’m not allowed to eat pork, and it is on my lunch tray.”
  5. “My mom does not like it when my room is messy.”

 

ANS: 3

  Feedback
1. The nurse has planned care to allow for prayer time for the patient.
2. The nurse understands the importance of family.
3. The nurse should have assessed dietary restrictions for the patient and ensured a proper diet is brought to the patient.
4. Family values play a role in the cultural practice of the family.

KEY: Content Area: Cultural Care | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Pediatric visitations should:
  2. Be 24 hours a day for parents and grandparents.
  3. Be semi-structured for other visitors.
  4. Provide time for socialization and playing.
  5. All of the above.

 

ANS: 4

  Feedback
1. Family-centered care is important to the healing process for the child.
2. Visits should be structured in order to allow the child time to rest.
3. Play helps decrease stress for the child.
4. All of the above statements should be included in visitations.

KEY: Content Area: Family-Centered Care | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension|  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A nurse promotes family-centered care when:
  2. Caregivers can room in and provide care to their child.
  3. The nurse provides the care as the physician orders.
  4. Care is provided after the family steps out of the room.
  5. Visitation guidelines are strictly followed.

 

ANS: 1

  Feedback
1. Including the family in providing care is being family centered.
2. The family needs to be involved in the care in order for it to be family centered.
3. Care should be provided continuously and hold the needs of the family and patient as a high priority.
4. Visitation guidelines are set by the family, not the staff.

KEY: Content Area: Family Care | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. When utilizing an interpreter, which item does not need to be documented?
  2. Name of the individual interpreting
  3. Primary language of the patient and caregiver
  4. Pictures used to communicate an idea
  5. Understanding of the patient and the care provider

 

ANS: 3

  Feedback
1. The name must be provided to verify who is giving the information.
2. The primary language documentation will provide future workers with information to help the patient.
3. If an interpreter is being used, pictures may only supplement the discussion. The interpreter should be communicating the health-care provider’s explanations word-for-word.
4. Clarity of the information provided through the interpreter should be documented to identify if the family is understanding the information provided.

KEY: Content Area: Legal Issues | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A nursing student understands pediatric cultural and dietary needs when she tells the parent of her patient:
  2. “You can bring in food from home.”
  3. “The hospital food should be adequate.”
  4. “I don’t know how the food is prepared.”
  5. “Food from home will only make your child miss home.”

 

ANS: 1

  Feedback
1. Food from home will comfort the child and help him/her understand the types of food that are seen as healthy choices in a time of illness.
2. Hospital food may not be prepared in the proper manner for consumption by some cultures.
3. Learning how the food is prepared will enable the staff to provide for the needs of the child.
4. Children will eat food that is familiar to them and is in compliance with their cultural and spiritual needs.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Staff education should include:
  2. Education on cultures common to their practice.
  3. Annual updates and reviews.
  4. Self-reflection on the care providers’ own values and beliefs.
  5. All of the above.

 

ANS: 4

  Feedback
1. Education should provide information about cultures the staff is not exposed to frequently.
2. Updates and reviews will allow staff to identify the needs of the patients on a continuous basis.
3. Self-reflection will identify biases and how not to let them interfere with the care provided to the patient.
4. All of the above answers should be included in staff education.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Spiritual assessments should be performed:
  2. During every contact with health-care providers.
  3. During hospitalizations.
  4. As needed.

 

ANS: 1

  Feedback
1. Spiritual assessments should be conducted during every contact with health-care providers. This would include well-child visits.
2. May need to know this information for immunizations and at well-child checkups.
3. Should be done at each visit in case the situation has changed for the patient.
4. Needs to be performed at every visit to identify changes in the spiritual needs.

KEY: Content Area: Legal Issues | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Effective communication can be confirmed when:
  2. The patient or caregiver asks questions.
  3. When the patient and caregiver do not verbalize questions.
  4. The receiver of the messages understands the information as the provider intended the message to be received.
  5. The receiver of the message speaks the same language as the person giving the message.

ANS: 3

  Feedback
1. Questions are asked to verify information and gather more information.
2. The patient and caregiver may need time to think about information before asking questions.
3. Effective communication entails understanding the message that the sender intended for the receiver.
4. The language does not determine the understanding of the patient or caregiver.

KEY: Content Area: Communication | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. When performing an initial assessment, the FICA Spiritual Assessment tool will:
  2. Help the care provider to include spiritual needs in the care plan.
  3. Will complete the questionnaire in the chart.
  4. Be answered by the parent or care provider.
  5. Only be answered by the patient.

 

ANS: 1

  Feedback
1. The FICA tool assesses faith, importance, community, and addresses care needs within the care plan.
2. Information will be gathered, but should not be the basis of the history or the care.
3. The child should be allowed to have input.
4. The family will have an influence on the spiritual care of the child.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. An example of a nurse-patient relationship would be:
  2. Attending a birthday party outside of the hospital.
  3. Providing special toys for favorite patients.
  4. Reporting suspected child abuse.
  5. Keeping a secret about suspected child abuse to keep confidentiality with the patient.

 

ANS: 3

  Feedback
1. The birthday party is beyond the professional boundaries of a nurse.
2. Demonstrating favoritism is not a professional action a nurse should display.
3. Nurses must report actual or suspected child abuse.
4. A nurse is a mandatory reporter and must report any suspicions of child abuse.

KEY: Content Area: Professionalism | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The medical clinic’s staff ensures quality multidisciplinary care by:
  2. Following hospital policies.
  3. Documenting and sharing all information.
  4. Not questioning other disciplines.
  5. Utilizing the correct form when obtaining data.

 

ANS: 2

  Feedback
1. Hospital policies may be unit and discipline specific.
2. Multidisciplinary relationships include sharing information and having respect for differences in opinion.
3. Questions should be asked in order to strive for the best care possible for a patient.
4. Forms are important, but do not always reflect needs of the entire staff.

KEY: Content Area: Professionalism | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Which finding most likely demonstrates lack of full disclosure?
  2. Health questionnaire completed in the waiting room
  3. Inability to explain how long symptoms have occurred
  4. Poor eye contact during exam
  5. Providing family history

 

ANS: 2

  Feedback
1. Others may be able to see the paperwork being filled out in a waiting room.
2. Potential embarrassment and disgrace to have a disease may prevent the patient or caregiver from discussing the length of symptoms.
3. Based on culture, eye contact may not be allowed.
4. Family history does not provide full disclosure of the needs of the patient.

KEY: Content Area: Professionalism | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A parent with a low-income job can get more groceries with less money when:
  2. Purchasing processed food.
  3. Purchasing fresh fruits and vegetables.
  4. Purchasing meat products.
  5. Purchasing snack foods.

 

ANS: 1

  Feedback
1. Processed foods are less expensive and have lower nutritional value than fresh foods.
2. Fresh fruits and vegetables tend to be higher priced in certain parts of the country because of the cost of shipping and the season.
3. Meat is expensive because of the cost of processing and shipping.
4. Snack foods come in small packages and do not provide nutritional content. Snack foods are more expensive for the quantity.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The nurse tells the caregivers of a 5-year-old patient that the patient will be discharged at lunch time. At 12:00 noon, the family is not present, but does come in at 2:00 p.m. The caregivers are wondering why the nurse thinks that they are late. This could be attributed to:
  2. Lack of discharge paper processing.
  3. Cultural differences in lunch time.
  4. The caregivers believing that the child is being watched adequately.
  5. The nurse being busy and losing track of time.

 

ANS: 2

  Feedback
1. The discharge paper processing cannot be completed without the caregivers being present.
2. Appointments should be made by clock time, not daily event times.
3. The caregivers may have a difference of opinion on time.
4. The later discharge occurred because the caregiver did not arrive at the set time.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The female caregiver of a patient wears a scarf that covers her head and face when males enter the room. The nurse noted that male nurses were entering the room without notice to the caregiver. The nurse’s best action would be to:
  2. No intervention is needed by the nurse.
  3. Place a sign on the door stating that all males must first knock and ask permission prior to entering the room.
  4. Only allow female caregivers.
  5. Only allow male caregivers.

 

ANS: 2

  Feedback
1. A plan should be made to help the female care provider feel at ease.
2. The family is considered the patient in pediatrics. Nurses should advocate and provide interventions that will maintain the cultural beliefs of the family unit.
3. Solely female caregivers may not be arranged because of staffing.
4. Solely male caregivers may not be arranged because of staffing.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Due to genetics, African American patients are at higher risk for:
  2. Liver cancer.
  3. Infectious diseases.

 

ANS: 4

  Feedback
1. Liver cancer is seen more in Caucasian males.
2. Injury is the highest risk factor for all ages of children, no matter the race.
3. Infectious diseases do not have a higher presence in one race over another.
4. African Americans are at a higher risk for diabetes due to genetics.

KEY: Content Area: Culture | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. European Americans may wear a horn charm to ward off evil spirits. They believe that diseases may be caused from a curse called:
  2. The evil spirit of the ancestors.
  3. The disease.
  4. The evil spell.
  5. The maloic.

 

ANS: 4

  Feedback
1. The curse of the evil spirits may be a reason to wear the horn.
2. The disease is not seen as an evil spirit.
3. The evil spell can be the outcome of  the disease process.
4. The maloic is the curse that is thought to cause disease.

KEY: Content Area: Culture | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Asian Americans may use this to cure diseases.
  2. Balance of hot and cold fluids
  3. Increased vegetable intake
  4. Increase in exercise to sweat out impurities
  5. Well-balanced diet

 

ANS: 1

  Feedback
1. Asians believe in the balance of hot and cold in the body.
2. Vegetables are common in the Asian American diet.
3. Exercise is not seen as a way to rid impurities of the body in order to help with an illness.
4. A well-balanced diet is important, but is not noted to be the cure of for diseases.

KEY: Content Area: Culture | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Spirituality can be defined as:
  2. Defining “God.”
  3. Feeling a greater being has control over world events.
  4. The concept of where and how the human race began.
  5. All of the above.

 

ANS: 4

  Feedback
1. God can come in different forms for all patients and caregivers.
2. A greater being gives a sense of control.
3. Ideas of how the human race began helps with coping for patients.
4. Spirituality is defining God, feeling a greater being has control over world events, and the concept of where and how the human race began.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. This religious affiliation may not accept blood products, so frequent blood draws and procedures that may involve blood loss should be limited.
  2. Atheism
  3. Buddhism
  4. Jehovah’s Witness
  5. Judaism

 

ANS: 3

  Feedback
1. Atheism does not have a belief system that affects any medical procedure.
2. Buddhism seeks a balance and will accept blood products.
3. Jehovah’s Witnesses may not accept blood transfusions.
4. Judaism allows for blood procedures.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. These two religious affiliations do not eat pork products.
  2. Muslim and Mormonism
  3. New Age and Atheism
  4. Judaism and Muslim
  5. Judaism and Buddhism

 

ANS: 3

  Feedback
1. Mormonism allows for pork products.
2. There are no diet restrictions for people of the New Age or Atheist faiths.
3. The Jewish and Muslim faiths do not permit the eating of pork.
4. A Buddhist does not have diet restrictions for pork.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. This religious group may need assistance with “ablution,” which is a process of washing prior to praying.
  2. Buddhist
  3. Christian
  4. Muslim
  5. Mormon

 

ANS: 3

  Feedback
1. Buddhists do not have the need for ablution.
2. Christianity does not require ablution prior to prayer time.
3. Those of the Muslim faith may need assistance with ablution prior to saying prayers.
4. Mormonism does not require ablution prior to prayer time.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Christians believe:
  2. Salvation comes from the belief that Jesus Christ died on the cross for all sins and transgressions.
  3. The day of rest is called “Sabbath” and occurs from sundown Friday to sundown on Saturday.
  4. Praying to ancestors will promote good karma.
  5. Life is comprised of suffering.

 

ANS: 1

  Feedback
1. Christians believe that salvation comes from Jesus Christ being a sacrifice for their sins when he died on the cross.
2. The Sabbath occurs on Sunday.
3. Karma and prayers for elders are not Christian practices.
4. Jesus Christ died for sins so suffering does not need to occur.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Family is best defined by:
  2. The patient.
  3. The family bloodline.
  4. The nurse.
  5. The care provider.

 

ANS: 1

  Feedback
1. Family members may not be blood related. The family is defined by who the patient and caregiver say is the family.
2. Family does not need to have a blood relation.
3. The nurse can be part of the family depending on the relationship with the patient.
4. The care provider can be part of the family.

KEY: Content Area: Culture | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Inadequate sidewalks in a community represent:
  2. A poor community.
  3. A community with few children.
  4. A community danger.
  5. An industrial community.

 

ANS: 3

  Feedback
1. Poverty is defined by the person, not the community.
2. Each community is different. Some have children and some do not. This cannot be determined by the condition of the sidewalks.
3. Inadequate sidewalks can represent a community danger.
4. The industrial community can be defined as a community element.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A child’s home environment will influence culture by:
  2. Promoting shelter from the elements of the weather.
  3. The child observing how to behave and respond to the environment.
  4. Providing a safe place to live.
  5. Providing a place to play and pretend.

 

ANS: 2

  Feedback
1. The shelter will have an element of culture, but it is not an influence.
2. Children learn about their culture by how their caregivers respond to the environment.
3. A safe place should be provided for all children.
4. A safe place is needed for play and pretend, but it is not influenced by culture.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A family from a different ethnic group comes into a clinic. A nurse thinks that they are not interacting well with her because they are not making direct eye contact. The nurse that thinks the family is not interacting well is demonstrating:
  2. Cultural competency.
  3. Cultural bias.
  4. Cultural diversity.
  5. Transcultural nursing.

 

ANS: 2

  Feedback
1. The nurse does not understand the culture and is not competent.
2. Cultural bias may occur when the nurse places his/her own values before the values of a different culture.
3. The nurse is not diverse in the understanding of other cultures.
4. Transcultural nursing identifies the cultural needs of a patient.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A nurse is caring for a child considered to be in spiritual distress. Spiritual distress can be described by the child as:
  2. “I feel better after I pray.”
  3. “I will trust in my God.”
  4. “I don’t agree with God’s decisions.”
  5. “I feel like God is punishing me.”

 

ANS: 4

  Feedback
1. Prayer is a form of comfort, not distress.
2. Trusting in a higher power does not demonstrate distress.
3. Not agreeing with God is a decision, not a demonstration of distress.
4. Spiritual distress is any alteration in spiritual health, as described by the patient or caregiver.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A fellow nursing student feels offended because the mother of her patient is invading her personal space. Your peer states that the “mom is a close talker and is right in my face.” You inform her that:
  2. The mom is wrong in invading her space.
  3. This might be a spacial norm for this mom’s culture.
  4. She should just ignore it until clinical is over.
  5. She should tell the mom not to stand so close when talking.

 

ANS: 2

  Feedback
1. The nurse does not understand the mother’s culture.
2. Spatial differences in communication may be different between cultures.
3. The nurse should speak with the mother to discuss the spacial issues.
4. The nurse should discuss the issue with the mother.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The mother of a critically ill baby just found out that her child is likely to die. She asks you to quickly contact a priest. The mom would like a prayer and baptism performed because the baby has yet to be baptized. Your best response would be:
  2. “Our chaplain usually comes in during the afternoon.”
  3. “I will have the secretary call for a priest.”
  4. “I will call for one as soon as I catch up with your child’s charting.”
  5. “Feel free to call your spiritual leader.”

 

ANS: 2

  Feedback
1. Notifying the chaplain right away will help ease the mother.
2. For some Christians, prayer and baptism for an infant can impact whether or not the baby goes to heaven.
3. Delegation for notifying the chaplain should occur.
4. The nursing staff should attempt to contact the priest to ease the situation for the mother.

KEY: Content Area: Culture | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The father of your patient wants the patient to ingest an herbal tea to help the child feel better. The nurse should:
  2. Allow the dad to give the patient the herbal tea.
  3. Evaluate if the herb will interact with any of the current medications or procedures that will be done.
  4. Ask the doctor.
  5. Not allow the child to ingest the herbal tea.

 

ANS: 2

  Feedback
1. The alternative medicine should be discussed with the medical provider prior to administration.
2. Parents may use alternative medicines when treating illnesses. The nurse should first assess for drug interactions and contraindications.
3. A discussion with the medical provider should occur, and the nurse should assess for drug interactions and contraindications.
4. If contraindications and interactions are not an issue, then the child can ingest the herb.

KEY: Content Area: Culture | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Transcultural nursing entails which of the following?
  2. Communication, space, beliefs, and time
  3. Communication, number of siblings, and skin color
  4. Space, number of siblings, and bedrooms
  5. Space, environment, and dialect

 

ANS: 1

  Feedback
1. These elements of transcultural nursing are included in Giger and Davidhizars’s Transcultural Assessment Model.
2. The number of siblings and skin color are not part of transcultural nursing.
3. The number of siblings and bedrooms are not part of transcultural nursing.
4. Dialect is not part of transcultural nursing.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. Leininger’s Cultural Care Theory includes the elements of:
  2. Values, beliefs, health, siblings, and culture.
  3. Values, beliefs, food, and culture.
  4. Values, beliefs, religion, lifestyles, and perceptions of health.
  5. Values, beliefs, and clothing.

 

ANS: 3

  Feedback
1. Siblings are not part of Leininger’s Cultural Care Theory.
2. Food is not part of Leininger’s Cultural Care Theory.
3. Leininger’s Cultural Care Theory includes culture, delivering culturally competent nursing, environmental context, family values, beliefs, lifestyles, and perceptions of health.
4. Clothing is not part of Leininger’s Cultural Care Theory.

KEY: Content Area: Culture | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. The care provider can individualize spiritual and cultural care by:
  2. Asking if there is a religious preference.
  3. Assessing the country of origin.
  4. Assessing needs that are verbalized by the patient.
  5. Assessing spiritual and cultural aspects of care and including the patient and caregivers in care planning.

 

ANS: 4

  Feedback
1. Asking about religious preference can be too straightforward for many patients.
2. A country of origin is not the only influence of spiritual and cultural care.
3. Verbalizing needs can help with gaining a full assessment because some people will not communicate their needs.
4. A spiritual and cultural assessment should be performed with each contact with care providers.

KEY: Content Area: Culture | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Application |  REF: Chapter 4 | Type: Multiple Choice

 

 

 

  1. A home health nurse is obtaining a cultural assessment on a family of five. The nurse should include which of the following in her assessment?
  2. Food preferences
  3. Religious beliefs
  4. Perceptions of the cause for disease
  5. All of the above are correct

 

ANS: 4

  Feedback
1. A part of cultural assessment, along with others
2. A part of cultural assessment, along with others
3. A part of cultural assessment, along with others
4. All are part of a cultural assessment.

KEY: Content Area: Culture | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance| Cognitive Level: Knowledge |  REF: Chapter 4 | Type: Multiple Response

 

 

 

Multiple Response

 

 

 

  1. Spirituality plays a role in the care of a patient. A nurse should be aware that spirituality consists of:
  2. Individualized definitions of God.
  3. Individualized concepts of how the human race began.
  4. Individualized concepts of what others should believe.
  5. Individualized concepts of a greater being who affects daily life.
  6. Individualized concepts of eternity.

 

ANS: 1, 2, 4,

  Feedback
1. Needed for a spirituality assessment
2. Needed for a spirituality assessment
3. This is an assessment of the individual’s belief system, not others.
4. Needed for a spirituality assessment
5. This is not assessed in a traditional spirituality assessment.

KEY: Content Area: Spirituality | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge |  REF: Chapter 4 | Type: Multiple Response

Chapter 11: Respiratory Disorders

 

 

 

Multiple Choice

 

 

 

  1. An 8-year-old child with a history of cystic fibrosis has a chest that is larger than normal. This type of feature on a child is known as:
  2. A concaved chest.
  3. A barrel chest.
  4. An asymmetrical chest.
  5. All of the above are correct.

 

ANS: 2

  Feedback
1. The chest does not bow inward in a child with cystic fibrosis.
2. A barrel chest is common in a child with cystic fibrosis because of the air trapping that occurs within the lungs.
3. The chest is symmetrical in appearance with cystic fibrosis.
4. Not all of the options are correct.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When a nurse enters the room of a child with chronic lung disease, she notes that the child is sitting in a tripod position. Identify the reason for this positioning by the child.
  2. The child feels more comfortable playing in this position.
  3. The child is attempting to have a bowel movement.
  4. The child is having trouble breathing, and the position is comfortable
  5. The child is in a resting position after walking in the hallway.

 

ANS: 3

  Feedback
1. The child may feel comfortable in this position, but it is not the primary reason for the positioning.
2. A child will squat on their haunches when having a bowel movement.
3. The tripod position enables the diaphragm to fully expand and attempt to get as much oxygen into the body as possible.
4. A child who is resting will sit or lie down on the bed.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When a child exhibits difficulty breathing, the best positioning would be:
  2. Having the head of the bed at 45 degrees.
  3. Placing the child in a 90 degree angle on the parent’s lap.
  4. Placing the child in a side lying position.
  5. Having the child sit in a chair.

 

ANS: 1

  Feedback
1. Positioning the head of the bed slightly elevated will take weight off of the diaphragm and allow for full chest expansion.
2. Placing the child at a 90 degree angle will put too much pressure on the diaphragm, thus causing the shortness of breath to continue.
3. A side lying position does not help to support the diaphragm or aid in relieving the shortness of breath.
4. Sitting in a chair will place more stress on the accessory muscles, thus the child will continue to have shortness of breath.

KEY: Content Area: Respiratory | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A father is concerned that his newborn baby girl is cold because her hands are blue. The nurse explains to the father that:
  2. This is a sign of respiratory distress, and the baby needs to return to the nursery.
  3. Most newborns have trouble regulating their body temperature.
  4. This is acrocyanosis and should go away within 48 hours after her birth.
  5. This is bruising the baby received during the birth process.

 

ANS: 3

  Feedback
1. Respiratory distress would be noted if the newborn had circumoral cyanosis.
2. Healthy newborns are able to regulate their body temperature soon after birth if dressed for the environment.
3. The newborn is exhibiting acrocyanosis. It is not a sign of coldness.
4. Bruising usually does not occur on the hands.

KEY: Content Area: Assessment | Integrated Processes: Teaching/Documentation | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is attempting to assess the skin color of a child with dark skin. The nurse knows the best place to assess the child’s skin color is:
  2. The nailbeds.
  3. Inside the mouth in the cheek area.
  4. The eyes.
  5. On the chest.

 

ANS: 2

  Feedback
1. The nailbeds should be used to assess capillary refill.
2. A pen light can be used to examine the inside of a child’s mouth in the cheek area for color.
3. The eyes can indicate jaundice, but not any other type of color changes.
4. Capillary refill can be assessed on the chest since the oral mucous membranes are more accurate.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child with respiratory distress can experience dehydration because:
  2. The child is not drinking enough fluids.
  3. The body requires an increased amount of fluids when sick.
  4. The child is retaining water in the kidneys since the body is using all the oxygen in the lungs.
  5. Mouth breathing occurs when in distress, so the child is losing hydration.

 

ANS: 4

  Feedback
1. Respiratory distress causes dehydration issues.
2. Fluids are required to keep mucous membranes and secretions moist, but are not the reason for dehydration.
3. Water is not retained in the kidneys with respiratory difficulties.
4. Children are known to be mouth breathers during respiratory distress situations, thus increasing their risk for dehydration due to the lack of moist mucous membranes.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When performing an assessment on an 8-year-old boy who is hospitalized for pneumonia, the nurse would anticipate what type of lung sounds?
  2. Crackles
  3. Stridor
  4. Normal
  5. Wheezes

 

ANS: 1

  Feedback
1. Fluid is built up in the lungs because of the infection, causing crackles to be heard.
2. Stridor is common in children with larynx issues, not pneumonia.
3. When fluid builds up in the lungs, it will cause the lung’s sounds to be abnormal with a diagnosis of pneumonia.
4. A child will have wheezes if the airway is constricted, not full of fluid.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 5-year-old child has been admitted for complications related to asthma. When the nurse auscultates the child’s lungs, she would anticipate hearing:
  2. Wheezes because the bronchioles have been restricted.
  3. Rhonchi because of thick secretions from the flare-up.
  4. Crackles because there is fluid in the alveoli.
  5. All of the above may be heard.

 

ANS: 1

  Feedback
1. Asthma constricts the airway and alveoli in children, causing wheezing to be heard when in auscultation.
2. Rhonchi usually will clear with a cough. A child with an asthma exacerbation will not stop the sound after coughing.
3. Asthma causes the narrowing of airways. Crackles occur only when fluid is present.
4. The airway and alveoli constriction causes wheezing.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When assessing a 12-year-old girl with the diagnosis of pneumonia, the nurse performs percussion. The lower left lobe is noted to have a dull sound. What should the nurse do next?
  2. Call the doctor with the assessment.
  3. Check the orders and start chest physiotherapy.
  4. Palpate the chest to check for tactile fremitus.
  5. Place the child on oxygen.

 

ANS: 4

  Feedback
1. The doctor will need to be called after oxygen is applied because the first priority is to maintain oxygen saturation in order to prevent further respiratory distress.
2. The child needs immediate intervention.
3. Tactile fremitus will be increased due to the pneumonia.
4. The assessment indicates that the child has a lower lobe that is not expanding and needs oxygen supplementation in order to maintain saturation levels.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child has the following ABG results:

pH: 7.38

pCO2: 52.6

HCO3: 32.5

The nurse interprets these results as:

  1. Compensated Respiratory Acidosis.
  2. Uncompensated Respiratory Alkalosis.
  3. Compensated Respiratory Alkalosis.
  4. Uncompensated Respiratory Acidosis.

 

ANS: 1

  Feedback
1. The pH is on the low end, creating a more acidotic state along with the CO2 in an acidotic state, thus indicating the respiratory acidosis. The HCO3 is alkalotic, creating compensation.
2. The pH and the CO2 are acidotic and the HCO3 is alkalotic, creating compensation.
3. The pH and CO2 are in acidotic states, not alkalotic states.
4. Compensation has occurred because of the HCO3 being alkalotic.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child’s ABG results are:

pH: 7.14

pCO2: 24.6

HCO3: 8.0

The nurse interprets these results as:

  1. Normal ABG.
  2. Partially Compensated Metabolic Acidosis.
  3. Uncompensated Metabolic Acidosis.
  4. Uncompensated Respiratory Acidosis.

 

ANS: 2

  Feedback
1. The pH is acidotic, the CO2 is alkalotic, and the HCO3 is acidotic. Because the pH and the HCO3 are acidotic, it causes the Metabolic Acidosis. Compensation occurs because the pH and the CO2 go in the opposite direction, and the pH is not in the normal range to cause the partial.
2. The pH is acidotic, the CO2 is alkalotic, and the HCO3 is acidotic. Because the pH and the HCO3 are acidotic, it causes the Metabolic Acidosis. Compensation occurs because the pH and the CO2 go in the opposite direction, and the pH is not in the normal range to cause the partial.
3. Compensation occurs because the pH and the CO2 go in the opposite direction, and the pH is not in the normal range to cause the partial.
4. Because the pH and the HCO3 are acidotic, it causes the Metabolic Acidosis.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child has the following results for an ABG:

pH: 7.42

pCO2: 43.9

HCO3: 26.8

The nurse interprets these results to be:

  1. Compensated Respiratory Acidosis.
  2. Compensated Respiratory Alkalosis.
  3. Normal ABG.
  4. Compensated Metabolic Acidosis.

 

ANS: 3

  Feedback
1. All results are within normal range and are not causing acidosis or compensation.
2. All results are within normal range and are not causing alkalosis or compensation.
3. All results are within normal ranges, thus this is a normal ABG finding.
4. All results are within normal range and are not causing compensation or acidosis.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 10-month-old boy is being given a sweat test because:
  2. The child has had several high fevers.
  3. The test is assessing for cystic fibrosis.
  4. The test is assessing for respiratory failure.
  5. The child does not demonstrate thermoregulation.

 

ANS: 2

  Feedback
1. A child with a high fever does not require a sweat test. Sweating can be a normal occurrence during fevers.
2. The sweat test is a common test for cystic fibrosis diagnostics.
3. The sweat test will not give an indication as to respiratory failure.
4. The sweat test does not deal with the thermal regulation of a child.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Otitis media is a common infection children have when an upper respiratory illness is present because:
  2. The Eustachian tubes are short and immature.
  3. The immune system is extremely compromised and more susceptible to infections.
  4. Bottle feeding increases the risk in babies.
  5. All of the above are correct.

 

ANS: 1

  Feedback
1. Eustachian tubes are short and do not provide adequate draining for mucous during an upper respiratory infection in children.
2. Immunity and susceptibility to infections cause the primary illness. Otitis media is a secondary illness.
3. A child that is positioned correctly during bottle feedings is not at an increased risk for otitis media.
4. Eustachian tubes are short and do not provide adequate draining for mucous during an upper respiratory infection in children, causing only one answer to be correct.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother has brought her 18-month-old boy into the pediatric clinic because of irritability, high fever, and has been tugging at his ear for the last 24 hours. The nurse would anticipate which of the following orders?
  2. Place the child NPO and attempt to get a head CT.
  3. Administering antibiotics for otitis media and acetaminophen for pain and fever control.
  4. No orders, as this is a common childhood ailment that requires no interventions.
  5. Admitting the child to the hospital to control the high fever.

 

ANS: 2

  Feedback
1. A child with a high fever is normally irritable and this would not be an indication for a head CT as a first priority.
2. The tugging at the ear can be an indication of a child having otitis media. Acetaminophen can help control the ear pain and fever in order to help decrease irritability.
3. Due to the high fever and irritability, the child is demonstrating pain. An intervention is needed.
4. Not enough information is provided to indicate the fever level. Normally this can be controlled at home with acetaminophen.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother calls the triage nurse because her 8-year-old son is having trouble keeping his balance, but has otherwise appeared healthy for the past few days. The nurse should advise the mother to:
  2. Make a doctor’s appointment because the child could have issues with his inner ear.
  3. Take the child immediately to the ER because this is a neurological emergency.
  4. Ask the child if he has consumed any drugs or alcohol in the last few days.
  5. Call back in a few days with an update.

 

ANS: 1

  Feedback
1. Unknown etiologies of unsteady balance are a sign of inner ear infections.
2. Since the mother feels the child is healthy and does not exhibit any other neurological symptoms, a doctor’s appointment is advisable.
3. A child would be exhibiting more symptoms than unsteady balance if he was taking a substance.
4. The concern should be addressed and an appointment made to find the cause of the unsteady balance.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Treatment for otitis externa (OE) is usually:
  2. No treatment because it resolves on its own.
  3. Antibiotic therapy.
  4. Corticosteroid therapy.
  5. Applying a warm pack to the area for comfort.

 

ANS: 3

  Feedback
1. Treatment is recommended because long-term or frequent infections can cause hearing loss.
2. The concern is the fluid and inflammation. Antibiotics will not help remove the fluid and inflammation.
3. Corticosteroids will help reduce the inflammation and fluid in the ear.
4. The warm pack can be a comfort measure, but the fluid and inflammation need to be addressed.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Important discharge teaching for a 4-year-old boy who had a tympanostomy procedure done would include:
  2. The tubes usually fall out spontaneously within a year.
  3. Draining of purulent fluid after two days, then return for a follow-up.
  4. Placing waterproof ear plugs in the ears when swimming.
  5. All of the above should be included in the discharge teaching.

 

ANS: 4

  Feedback
1. Because of the rapid growth of children, the tubes usually last approximately one year.
2. Purulent fluid is a sign of infection.
3. Preventing water from entering the tubes will help decrease the chance of infection.
4. Because of the rapid growth of children, the tubes usually last approximately one year. Purulent fluid is a sign of infection. Preventing water from entering the tubes will help decrease the chance for infection.

KEY: Content Area: HEENT | Integrated Processes: Teaching/Documentation | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An outbreak of influenza has occurred at the middle school. The school nurse is preparing to send home information about influenza. Her flyer should include all of the following except:
  2. The virus is contagious one to two days prior to the appearance of symptoms.
  3. Do not send your child to school if he/she has the chills or a erythematous rash.
  4. Hydration is important.
  5. If your child vomits, take them to the emergency room immediately.

 

ANS: 4

  Feedback
1. The virus is most contagious one to two days prior to the appearance of symptoms.
2. Chills and a erythematous rash indicate fever and can cause the spread of the virus.
3. Hydration will help keep mucous membranes moist to remove secretions.
4. Vomiting may occur and is not a medical emergency.

KEY: Content Area: Illness | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Amantadine hydrochloride has been prescribed for a patient. The nurse knows this medication is used for:
  2. Sinusitis.
  3. Influenza.
  4. Upper respiratory tract infections.
  5. Asthma.

 

ANS: 2

  Feedback
1. The medication is not prescribed for sinusitis.
2. The medication helps reduce the symptoms and spread of the influenza virus.
3. Upper respiratory tract infections do not benefit from the use of the medication.
4. Asthma exacerbations do not benefit from the use of this medication.

KEY: Content Area: Illness | Integrated Processes: Nursing Process| Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child is scheduled to have a tonsillectomy in two hours. The nurse’s assessment should include:
  2. A question to see if the child snores or has difficulty breathing at times.
  3. Assessing for halitosis.
  4. The size of the tonsils.
  5. All of the above

 

ANS: 4

  Feedback
1. Snoring and difficulty breathing are an indication of obstruction of the tonsils.
2. Halitosis is common in children with enlarged tonsils because of the bacterial content.
3. Tonsil size should be documented because removal of the entire tissue will need to occur during surgery.
4. Snoring and difficulty breathing are an indication of obstruction of the tonsils. Halitosis is common in children with enlarged tonsils because of the bacterial content. Tonsil size should be documented because removal of the entire tissue will need to occur during surgery.

KEY: Content Area: HEENT | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Following a tonsillectomy, a nurse should provide the patient with:
  2. Ice chips, no pillow, and no straw for drinking.
  3. Ice chips and orange juice.
  4. A sippy cup and pudding.
  5. A pillow, red Gatorade, and a straw.

 

ANS: 1

  Feedback
1. The patient should lie flat to help clotting occur, ice chips will provide hydration, and no straw should be given because this can cause the clots to break and increase bleeding.
2. Orange juice should not be used because the pulp may lodge into the surgical site.
3. A sippy cup can cause clots to break because of the sucking motion and pudding is too thick to swallow at this point.
4. A patient should lie flat to help with clotting, Gatorade should not be used because you cannot assess for blood because of the color, and a straw will cause the clots to break and increase bleeding.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn is lying in his crib in the hospital nursery. The nurse picks up the newborn to prepare for a feeding and notes frothy oral secretions around the newborn’s mouth. The nurse should:
  2. Wipe the newborn’s mouth and give the feeding.
  3. Clean the newborn’s mouth and notify the doctor of the findings.
  4. Feed the newborn.
  5. Take the baby to the mother to feed.

 

ANS: 2

  Feedback
1. The wiping the mouth for an assessment is needed, but the newborn should not be fed because the secretions are an indication of lack of secretion drainage.
2. These actions should occur because the child is at risk for tracheal esophageal atresia.
3. The newborn should not be fed because the secretions are an indication of lack of secretion drainage and increases the chance for aspiration.
4. The newborn should not be fed because the secretions are an indication of lack of secretion drainage and increase the chance for aspiration.

KEY: Content Area: Respiratory | Integrated Processes: Care | Client Need: Safe and Effective Care Environment | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn has had a repair of a trancheoesophageal fistula one hour ago. When the newborn is taken to the neonatal intensive care unit, the nurse should:
  2. Monitor the oxygen saturations of the newborn.
  3. Assess for respiratory distress.
  4. Provide oral suctioning as needed.
  5. All of the above should be done for the newborn.

 

ANS: 4

  Feedback
1. Oxygen saturations will indicate the respiratory status of the newborn.
2. Assessment for respiratory distress is needed because the surgery requires some trauma to the trachea.
3. Suctioning is needed so the secretions do not cause blockage in the airway.
4. Oxygen saturations will indicate the respiratory status of the newborn. Assessment for respiratory distress is needed because the surgery requires some trauma to the trachea. Suctioning is needed so the secretions do not cause blockage in the airway.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother calls the pediatric triage nurse to report that her son has a barky cough, and it started about midnight. The nurse should instruct the mother to:
  2. Take the child to the emergency room right away.
  3. Sleep with the child in an upright position.
  4. Take the child into a room with a cool mist humidifier or go outside and see if the barky cough subsides.
  5. All of the above would be appropriate responses for the mother.

 

ANS: 3

  Feedback
1. The mother should attempt to relieve the symptoms at home prior to coming to the emergency room.
2. The child will more than likely not sleep.
3. A cool mist humidifier or going outside can help reduce the inflammation of the trachea and larynx area.
4. Only using the cool mist humidifier or taking this child into the cool night is effective treatment.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When assessing a child with epiglotitus, the nurse should assess for all of the following except:
  2. Drooling.
  3. Dysphonia.
  4. Stridor.
  5. Crackles in the upper lungs.

 

ANS: 4

  Feedback
1. Drooling can indicate swelling of the epiglottitis because the secretions are not able to go to the stomach.
2. Dysphonia can occur because of the swelling.
3. Stridor is common because of the swelling of the epiglottitis.
4. Crackles are heard in lower respiratory illnesses, not the upper respiratory illnesses in children.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 2 year old has been placed in contact isolation because of a diagnosis of Respiratory Syncytial Virus (RSV). The father questions why the staff is wearing masks and gowns every time someone comes into the room. The best response would be:
  2. “The equipment is needed to protect myself and others from your child’s illness.”
  3. “Since bronchiolitis is highly contagious for other children, it is important for the staff to wear the equipment to prevent spreading it to others.”
  4. “Every child that comes in with a respiratory illness is required to be in isolation.”
  5. “The equipment is needed to protect your child from acquiring an illness from the staff.”

 

ANS: 2

  Feedback
1. The equipment is protecting the health-care worker from transmitting the virus to other patients.
2. Prevention of the spread of the disease is the primary reason for the equipment.
3. Not all respiratory illnesses require isolation.
4. The equipment is protecting the health-care worker from transmitting the virus to other patients.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a 3-month-old child with RSV. The nurse identifies the following: HR of 140; RR of 32; Oxygen saturation is 89% on room air; inspiratory and expiratory wheezing of the upper lungs; temperature of 38.1 degrees Celsius; large amounts of thin secretions. Identify the priority at this time.
  2. Administering acetaminophen to reduce the fever
  3. Providing oxygen for the low saturation
  4. Suctioning the nares and oropharnyx to remove the secretions
  5. Providing a quiet environment

 

ANS: 3

  Feedback
1. The fever is low grade and not a priority at this time.
2. 89 percent oxygen saturation on room air needs to have a further assessment to see why the child is low in saturations.
3. Suctioning helps remove all the secretions and opens the airway with the possibility of increasing oxygen saturations.
4. A quiet environment will help the child rest, but is not a priority at this time.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A common cause of viral pneumonia in children is:
  2. The influenza virus.
  3. Streptococcus.
  4. Fungus.
  5. Beta-hemolytic streptococcus pneumoni.

 

ANS: 1

  Feedback
1. Influenza is a common cause for viral pneumonia in children as a secondary infection.
2. Streptococcus is a bacterium, not a virus.
3. Fungus is not a virus.
4. Beta-hemolytic strep is bacterial, not viral.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The best way to prevent pertussis in children is with:
  2. Good hand hygiene.
  3. Keeping immunizations up-to-date.
  4. Isolation precautions.
  5. All of the above are correct.

 

ANS: 2

  Feedback
1. Hand hygiene is important but the pertussis virus is usually airborne.
2. Immunizations help to build immunity to the disease.
3. Isolation precautions are needed after a child has the illness.
4. Immunizations to help build immunity to the disease is the priority.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A school nurse has been made aware that an eighth grader has latent tuberculosis (TB). Education for the teaching staff should include:
  2. A document with the signs and symptoms of illness for a person with TB.
  3. Do not allow the child into the classroom when he coughs. Send him to the nurse’s office to prevent the spread of the illness.
  4. Provide universal precautions with the child.
  5. The child does not need any interventions at this time because the TB is dormant.

 

ANS: 1

  Feedback
1. A signs and symptoms document will help increase the awareness of the disease and can also help identify those who are infected early.
2. The spread of the disease cannot occur just because of coughing.
3. Universal precautions should be used with every student, not just the ill children.
4. Interventions will help prevent the illness from spreading.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A neonate has been diagnosed with respiratory distress syndrome. The nurse notes the neonate is retracting and is hypoxic. The best intervention at this time would be:
  2. Providing oxygen support via a mask.
  3. Providing oxygen support via nasal cannula.
  4. Attempt to reposition the neonate.
  5. Check the temperature of the neonate so that the child does not experience cold stress.

 

ANS: 1

  Feedback
1. Oxygen delivered by mask is the highest percentage of oxygen to be delivered other than intubation.
2. The neonate does not receive as high of a rate of oxygen saturation with a nasal cannula.
3. Repositioning may open the airway more, but the retracting occurs because of deterioration, thus requiring oxygen support.
4. Cold stress can cause respiratory issues, but is short term once the neonate is warm.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When assessing a newborn with a known diaphragmatic hernia, the nurse would anticipate hearing bowel sounds:
  2. In the upper abdomen.
  3. In the lower abdomen.
  4. To not exist.
  5. In the chest.

 

ANS: 4

  Feedback
1. Normal bowel sounds can be heard in the upper abdomen.
2. Normal bowel sounds can be heard in the lower abdomen.
3. Bowel sounds do exist, just in a different area of the body.
4. Because of the lack of diaphragm, the gastrointestinal tract is shifted into the chest cavity.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is repositioning an infant with a known diaphragmatic hernia. The nurse should place the infant in which position?
  2. With the head of bed elevated 20 degrees
  3. Supine
  4. Prone
  5. In a semi-fowlers position

 

ANS: 4

  Feedback
1. This position does not take enough pressure off of the respiratory muscles.
2. Supine can cause the collapsing of the chest cavity and increase difficulty breathing.
3. Prone can cause too much pressure on the respiratory muscles and not allow for expansion.
4. Semi-fowlers will allow for pressure to be taken off of the diaphragm and decrease difficulty breathing.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Clubbing of the nailbeds in the fingers would be a clinical finding on which patient?
  2. A child with cystic fibrosis
  3. A child with croup
  4. A child with respiratory distress syndrome
  5. A child with RSV

 

ANS: 1

  Feedback
1. Long-term hypoxia causes clubbing of the nailbeds because of the lack of oxygen.
2. Croup is a short-term respiratory issue, which does not causing clubbing.
3. Respiratory distress syndrome is short lived and does not cause clubbing.
4. RSV is short lived and does not cause clubbing.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Children with cystic fibrosis should be frequently checked for:
  2. Hypernatremia.
  3. Hypocalcemia.
  4. Hyponatremia.
  5. Hypercalcemia.

 

ANS: 3

  Feedback
1. High sodium is not an issue in children with cystic fibrosis.
2. Low calcium levels are not an issue for children with cystic fibrosis.
3. The lack of sodium is noted in children with this diagnosis.
4. High calcium levels are not common in children with cystic fibrosis.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An 8-year-old boy with a long history with cystic fibrosis has been admitted for malnutrition. The doctor has ordered labs for the child. The nurse clarifies which doctor’s order before proceeding?
  2. Obtain a stool sample for Clostridium difficile
  3. Metabolic panel for hydration status
  4. Serum albumin level to measure the nutritional status
  5. Provide chest physiotherapy before bedtime

 

ANS: 1

  Feedback
1. A stool sample should be used for the absence of trypsin.
2. Malnutrition may be caused by metabolic issues.
3. Serum albumin levels will help indicate nutritional status and are appropriate for this patient.
4. Chest physiotherapy is needed at bedtime to rid as many secretions as possible prior to lower activity levels.

KEY: Content Area: Respiratory | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Teaching a child with a chronic respiratory illness to forcefully exhale can be done by:
  2. Pretending to blow candles out.
  3. Blowing bubbles.
  4. Pretending to blow out a flashlight.
  5. All of the above are techniques for teaching a child to forcefully exhale.

 

ANS: 4

  Feedback
1. This requires a large volume for inhalation and expiration, thus being an effective treatment.
2. This requires pursed-lip breathing and helps force air, thus being an effective treatment.
3. This requires a large volume for inhalation and expiration, thus being effective treatment.
4. Pretending to blow out candles or a flashlight require a large volume for inhalation and expiration, thus being effective treatment. Blowing bubbles requires pursed-lip breathing and helps force air, thus being an effective treatment.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A diet for a child with cystic fibrosis should include:
  2. Foods with high protein and high fat content.
  3. Foods with low fat and high protein content.
  4. A daily dose of fat-soluble vitamin supplements.
  5. A daily dose of water-soluble vitamin supplements.

 

ANS: 3

  Feedback
1. A diet with a high fat content can cause digestion issues because of the lack of enzymes.
2. A diet with low protein is needed for the child to aid in health.
3. The fat-soluble vitamins are needed because the child is not able to digest fat easily.
4. A child with cystic fibrosis should be able to receive the needed water-soluble vitamins in a regular diet.

KEY: Content Area: Nutrition | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is attempting to educate a 10-year-old girl in the use of a peak flow meter. Identify the best way to explain the test to the child.
  2. “The purpose of the test is to see how hard you breathe.”
  3. “The purpose of the test is for you to monitor what is normal and abnormal for you. Then your parents can help with your medication on days when you are not measuring in your normal ranges.”

3: “We are measuring how well you can blow birthday candles out.”

  1. “The meter will help monitor when you are healthy and when you are becoming ill.”

 

ANS: 4

  Feedback
1. The description is not accurate, and a 10 year old is able to comprehend the reason for use of a peak flow meter.
2. The description of normal and abnormal can cause concern for the child. It is important to explain that the peak flow meter is a measurement of health.
3. This description can be used for a younger child. A 10 year old is able to comprehend the use of the peak flow meter.
4. The peak flow meter is a monitor used to indicate when the child is breathing easily and when illness may be starting.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn is experiencing apneic episodes. The nurse should do which of the following when an episode occurs?
  2. Give the newborn CPR
  3. Stimulate the newborn by rubbing its back
  4. Reposition the newborn
  5. Hold the newborn

 

ANS: 2

  Feedback
1. An assessment to see if the newborn has a heart rate is needed.
2. Stimulating the newborn may help his/her breathing.
3. Repositioning the newborn is important and should occur after breathing stimulation is provided.
4. Holding the newborn will not stimulate him/her to breathe.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A former 24-week, premature infant is now adjusted in age to be one year of age. The baby has a known history of bronchopulmonary dysplasia. The parents of the child are asking if their baby will catch up in height and weight to her peers by the time she is 2 years old. The best reply from the nurse would be:
  2. “Normally, premature infants will be the same height and weight as their peers by their second birthday.”
  3. “The bronchopulmonary dysplasia requires your child’s lungs to work harder to breath. This causes the body to have a higher metabolism, so she may remain on the small side for several years.”
  4. “You baby is now healthy and will continue to grow at her own rate.”
  5. “Your baby will remain small for most of her life due to the bronchopulmonary dysplasia.”

 

ANS: 2

  Feedback
1. Children with bronchopulmonary dysplasia require high nutritional demands to the body. The growth of children with this diagnosis tends to be slower than their peers.
2. Children with this diagnosis tend to be smaller than their peers for a longer period of time.
3. This is a true statement, but does not address why the child is not growing at the same rate.
4. The child’s body can grow and may be the same as peers later in life.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The nurse is assessing a child that was in a motor vehicle accident, which occurred two hours ago. The child’s chest is not rising on the right and lacks lung sounds. The X-ray confirmed a hemothorax. The nurse should anticipate the order for:
  2. A chest tube and pnuemovac.
  3. IV fluids.
  4. Placing a nasogastric tube.
  5. None of the above would be appropriate for the situation.

 

ANS: 1

  Feedback
1. The pnuemovac will aid in the creation of a sterile container to help decompress the hemothorax.
2. IV fluids may be ordered eventually, but they are not a priority at this time. Airway security is the priority.
3. A nasogastric tube will not influence the hemothorax.
4. The nurse should anticipate the use of the pneumovac to help decompress the hemothorax.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The purpose of administering surfactant to a preterm neonate is:
  2. Because the preterm neonates lungs do not produce it.
  3. To prevent the alveoli from collapsing.
  4. To help the diaphragm function.
  5. Because a preterm neonate needs more surfactant than an older child.

 

ANS: 2

  Feedback
1. Preterm neonates do have some surfactant in the lungs, but not enough to keep the alveoli open for a long period of time.
2. Surfactant is the lubricant in the lungs that allows all for alveoli to remain moist and prevents them from collapsing.
3. The diaphragm is outside of the lung tissue and does not receive surfactant.
4. A preterm neonate’s needs do not differ from those of an older child.

KEY: Content Area: Respiratory | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The mother of a child with cystic fibrosis calls the triage nurse and asks which type of antihistamine would be the most beneficial for her son’s head cold. The nurse should:
  2. Recommend Benadryl for her son.
  3. Discourage the use of antihistamines because the drug can dry out the mucous and make it harder to expel.
  4. Encourage the mother to give the child a dose of the antihistamine every four hours.
  5. Recommend any over-the-counter antihistamine that states it is a pediatric formula.

 

ANS: 2

  Feedback
1. Benadryl will dry out the mucous membranes and cause further problems for the child.
2. Discouragement of antihistamine usage is important because the medication can dry out the mucous membranes too much for a child with cystic fibrosis.
3. Antihistamine medication can dry out the mucous membranes too much for a child with cystic fibrosis, creating further problems.
4. Antihistamine medication can dry out the mucous membranes too much for a child with cystic fibrosis and create further problems.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The mother of an 18 month old states that she is concerned due to the fact that her child has been diagnosed with otitis media three times in the last year. Which answer would be appropriate to alleviate the mother’s concerns?
  2. A child’s airway is short and narrow. As the child grows, the airway will grow, and the number of alveoli will increase.
  3. A child’s tonsils are larger than an adult’s and block emptying of the Eustachian tubes. As the child grows, the tubes get longer even though tonsils don’t change.
  4. A child’s Eustachian tubes are shorter and more horizontal, allowing nasopharyngeal secretions to enter. As the child grows, the incidence of OM will decrease.
  5. A child’s larynx is more flexible than an adult’s and easily stimulated to spasm. As he grows, he will be less sensitive to laryngospasms and pooling of secretions.

 

ANS: 3

   
1. Although choice 1 is correct, it does not address the ears and recurrent infection.
2. A child’s tonsils are not larger than an adult’s. They do not block the emptying of the Eustachian tubes.
3. A child’s Eustachian tubes are shorter and more horizontal, allowing nasopharyngeal secretions to enter. As the child grows, the incidence of OM will decrease.
4. A child’s larynx is not more flexible than an adult’s.

KEY: Content Area: Basic Care and Comfort | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The mother of a 3 year old complains to the nurse after the physician leaves the room, saying, “My baby is sick with a fever, bad cough, runny nose, and flushed cheeks. He didn’t give me any medicine to make him better!” What is the nurse’s best response?

 

  1. “It is okay to give your child over-the-counter medicine. Just make sure you get a cold and fever medication.”
  2. “The doctor stated that he believes this to be a virus, so antibiotics will not relieve the symptoms.”
  3. “The best way to treat your child is to give him plenty of fluids, bedrest, and coloring books.”
  4. “The doctor believes this to be a viral illness, so you can use over-the-counter cold medications as long as they say ‘pediatric’ on the label.”

 

ANS: 2

   
1. You should not use cold medicine in children under the age of 5.
2.  “The doctor stated that he believes this to be a virus, so antibiotics will not relieve the symptoms.”

 

3. Fluids, bedrest, and limiting contacts would help the management of current symptoms. This does not address the mother’s concern of not receiving medication.
4. You should not use cold medicine in children under the age of 5.

KEY: Content Area: Comfort and Care | Integrated Processes: Teaching Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 6 year old had a tonsillectomy today. When the nurse goes into the room to give him his antibiotics, she finds him irritable, coughing, nauseated, and swallowing repeatedly. What is the next action the nurse should take?
  2. Assess for signs of frank red blood in the mouth and nose and get a complete set of vital signs.
  3. Ask the child for a pain score and if he would like a popsicle with his pain medicine.
  4. Suction mouth vigorously to avoid aspiration of blood, and then hang antibiotic.
  5. Take a complete set of vital signs and divert the child’s attention to the cartoon on TV.

 

ANS: 1

  Feedback
1. This intervention assesses for bleeding.
2. An assessment for blood needs to occur because the child continues to swallow.
3. Suctioning can cause clots to loosen and increases bleeding. It should be avoided.
4. Vital signs are needed and a focused assessment needs to be completed in order to identify complications.

KEY: Content Area: Care and Comfort | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A father brings his 6-month-old infant into the clinic with a four day history of nighttime, seal-like cough. The infant is afebrile, tachycardic, and tachypneic with a pulse oximetry reading of 98 percent. What interventions would you expect the physician to order for this child?
  2. Cool mist tent with supplemental oxygen, racemic epinephrine, and corticosteroids
  3. Beta adrenergics aerosolized, cool mist tent, and periodic testing of blood glucose levels
  4. Close monitoring of respiratory status, cool mist tent, beta adrenergics, and corticosteroids
  5. Close monitoring of respiratory status, supplemental oxygen with simple mask, and racemic epinephrine

 

ANS: 3

  Feedback
1. The infant’s pulse oximetry is 98 percent and does not need supplemental oxygen.
2. Beta adrenergic meds do not increase blood glucose levels.
3. These interventions are appropriate for croup-like symptoms.
4. The infant’s pulse oximetry is 98 percent and does not need supplemental oxygen.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An 8 month old was admitted to the hospital last night with cold symptoms and respiratory distress. She is on a simple mask with a flow rate of 10 L and on a cardiorespiratory monitor. The nurse goes into the infant’s room to find her tachypneic, retracting, and slightly cyanotic with a pulse oximetry of 90%. What would be the oxygen delivery system that may help the infant?
  2. A venturi mask with an oxygen flow of 1 liter per minute.
  3. A nasal cannula with an oxygen flow of 4 liters per minute.
  4. An oxygen tent with an oxygen flow rate of 10 liters per minute.
  5. A partial rebreather mask with an oxygen flow rate of 8 liters per minute.

 

ANS: 4

  Feedback
1. The pressure is not adequate to oxygenate the infant.
2. A nasal cannula does not deliver enough pure oxygen to raise the oxygen saturation of the infant.
3. The oxygen tent will not allow for enough pressure for the infant to raise the oxygen saturation.
4. A partial rebreather mask with an oxygen flow rate of 8 liters per minute will raise the oxygen saturation of the infant.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother brought her 8 year old into the emergency room because although she was fine when she woke up this morning, she now has a fever of 39.8 C, cannot speak, is drooling, and is tachypneic and stridorous. Her pulse oximetry reading is 90 percent on a rebreather mask. What would be the next appropriate nursing action?
  2. Suction her mouth, then conduct throat and blood cultures as well as a test for gram positive bacteria.
  3. Prepare the child and mother for an MRI scan to evaluate for a “thumb sign.”
  4. Monitor respiratory status closely, prepare for intubation, and keep the child calm to avoid crying.
  5. Suction her mouth, monitor respiratory status closely, and give a Palivizumab injection.

 

ANS: 3

  Feedback
1. Suctioning can cause more traumas to the area.
2. The “thumb sign” will not occur in this condition.
3. The nurse would monitor and be prepared for possible rapid decline in respiratory status and try to keep the child from crying.
4. Suctioning the mouth can cause more damage, and the injection should not be given at this time.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. What is the most accurate statement regarding Palivizumab?
  2. It is a humanized monoclonal antibody given as an IM injection before the start of HPV season.
  3. It is recommended for premature infants with 29-35 week’s gestation, children with congenital heart defects, and the elderly.
  4. It is costly and is given usually between October to May in a series of five injections.
  5. Before administering, you need to evaluate results of complete blood count and electrolyte panel from the laboratory.

 

ANS: 3

  Feedback
1.  Given prior to RSV season
2. Not given to the elderly
3. It is given prophylactically before the start of RSV season. The nurse needs to evaluate platelets and coagulants before administering.
4. The nurse needs to evaluate platelets and coagulants before administering.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 15 month old admitted with croup is sleeping in a cool mist tent. The nurse checks on him and notices that he is retracting and tachypneic. What is the first thing she should do?
  2. Increase the oxygen flow to the tent
  3. Check the child’s pulse oximetry
  4. Check the child’s temperature
  5. Notify the physician

 

ANS: 2

  Feedback
1. This is not the first intervention. A pulse oximetry should be assessed to identify the need for oxygen.
2. The first intervention should be to check the child’s pulse oximetry.
3. Fever can cause tachypnea. This is not the first action needed.
4. Notifying the physician is not the first action needed.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An infant born an hour ago exhibits coughing and drooling, cyanosis, abdominal distention, and moderate retractions and grunting. Based on these symptoms, what would be the most likely diagnosis?
  2. Tracheoesophageal fistula
  3. Laryngomalacia
  4. Respiratory distress syndrome
  5. Bronchopulmonary dysplasia

 

ANS: 1

  Feedback
1. Tracheoesophageal fistula is the most likely diagnosis.
2. Laryngomalacia would cause more grunting.
3. The child may initially present similar respiratory distress, but the drooling indicates that more is involved.
4.  Bronchopulmonary dysplasia occurs after long-term ventilator support, not soon after birth.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 12 year old comes in with her mother and has the following symptoms: a 40.0 C fever, chills, coughing, and chest pains. Her mother states that she just finished Amoxicillin for strep throat and her chest x-ray shows consolidation. Based on these findings, what would be possible nursing interventions to manage this patient?
  2. Monitor oxygenation status and results of sputum culture, CBC, PTT, and sweat chloride test from the laboratory
  3. Monitor respiratory, oxygenation, and hydration status and give antibiotics as ordered
  4. Monitor respiratory and oxygenation status and give pneumococcal vaccine injection as ordered
  5. Monitor oxygenation and hydration status and inform mother that antibiotics would be ineffective for her daughter

 

ANS: 2

  Feedback
1. A PTT and sweat chloride test are not needed at this time because this is the initial incidence of respiratory issues.
2. Although RSV causes 80%85% of all pneumonia in children, the nurse suspects bacterial pneumonia due to the recent strep infection. This is why antibiotics are expected to be ordered.
3. A pneumococcal vaccine should be given prior to the illness.
4. Although RSV causes 80%85% of all pneumonia in children, the nurse suspects bacterial pneumonia due to the recent strep infection. Antibiotics can be effective in this situation.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. It is May, and a mother brings in her 3-year-old son, who has had a harsh whooping cough, runny nose, and watery eyes for the past five days. What would be the most appropriate question to ask the mother?
  2. Are the child’s immunizations up-to-date, including his Tdap vaccine?
  3. Did the child receive his Hib vaccine?
  4. Have you taken the child outside in the rain? If so, what happened?
  5. When was the last time your child was ill?

 

ANS: 1

  Feedback
1. Up-to-date immunizations will include the Tdap vaccine.  If the child has had the vaccine the occurrence/severity of the illness is less.
2. Hib does not include the Whooping Cough vaccine.  The question would not be appropriate at this time.
3. Weather does not influence the vaccines.
4. Past illnesses is not the focus of the current assessment and is not appropriate at this time.

KEY: Content Area: Wellness | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. You suspect a 14 year old with persistent cough, anorexia, low-grade fever, and night sweats has tuberculosis. What is the most accurate statement about the treatment of this patient?
  2. A nurse needs to collect serial sputum cultures in the a.m. and do serial AFB tests.
  3. Latent TB would be treated with antituberculin medication combinations in higher doses for nine months.
  4. Anti-tubercular medications given in higher doses in combination for six months are only effective after BCG vaccine is given.
  5. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.

 

ANS: 4

  Feedback
1. The time of day does not influence when the sample should be taken.
2. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.
3. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.
4. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Which statement regarding the pathophysiology of TB is accurate?
  2. The settling of the bacillus in the alveoli triggers the clotting response.
  3. Macrophages form hard tubercules around bacilli that always remain dormant in the lungs.
  4. TB can affect the lungs, spinal cord, bone formation and the brain.
  5. Tubercles in the lungs can remain dormant or progress to active tuberculosis, but are not as prevalent in children.

 

ANS: 4

  Feedback
1. The clotting response is not triggered by the bacillus.
2. The tubercules are rare in children.
3. TB affects the lungs only.
4. Tubercles in the lungs can remain dormant or progress to active tuberculosis, but are not as prevalent in children.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The nurse is doing discharge teaching with the mother of a 10 year old, who has been newly diagnosed with TB. Which statement is not accurate regarding the spread of TB?
  2. The patient should take anti-tubercular medicine for two weeks before being exposed to any non-infected people.
  3. Everyone should wash their hands or use sanitizer after exposure to respiratory secretions.
  4. It is transmitted through inhaled droplets from a close contact that is infected.
  5. About 460,000 new cases of multi-drug sensitive TB are reported every year because of incomplete treatment regimes.

 

ANS: 4

  Feedback
1. The medication will be needed for this length of time before being exposed to others.
2. Washing of hands should occur with every patient.
3. Close contact with those who have the disease increases the risk.
4.  This statement is not accurate.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn, premature twin exhibits respiratory distress with retractions, nasal flaring, cyanosis, grunting, and fine, scattered rales. What nursing interventions would you expect the physician to order?
  2. Place an NG tube for feeds, monitor respiratory status on ventilator, record I& O’s, start an IV, and send electrolyte panel to the laboratory and monitor temperatures
  3. Cardio- respiratory monitoring, frequent suctioning on ventilator, and monitoring blood glucose level hourly
  4. Placing infant in semi-fowler’s position on affected side with head of the bed elevated, oxygen via nasal cannula, keeping NPO, and preparing parents for surgery
  5. Giving surfactant intravenously within the first 12 hours of life and repeating every 12 hours for three days.

 

ANS: 1

  Feedback
1. Place an NG tube for feeds, monitor respiratory status on ventilator, record I& O’s, start an IV, and send electrolyte panel to the lab and monitor temperatures
2. A ventilator is not needed at this time. Blood glucose should be monitored because it can cause an increase in respiratory distress.
3. Surgery is not indicated at this time.
4. The statement does not indicate the level of prematurity for the infant. Surfactant is not needed at this particular time.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn has a scaphoid-shaped abdomen, irregular chest wall movements, and decreased breath sounds on the left side of chest. What other symptoms would you expect to find?
  2. Central cyanosis and pink nailbeds with brisk capillary refill
  3. Protruding abdomen and fullness with palpation
  4. Increased breath sounds over trachea, tachypnea, and stidor
  5. Tachypnea, nasal flaring, and retractions

 

ANS: 4

  Feedback
1. Nailbeds will be cyanotic and exhibit slow capillary refill.
2. The abdomen will be full and stiff because of excessive air.
3. Grunting may be present, and there will be decreased breath sounds.
4. Tachypnea, nasal flaring, and retractions are the correct symptoms.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Cystic fibrosis is best categorized as:

 

  1. An autosomal recessive disease with deletion of Chromosome 17 that affects the lungs and finances of the parents.
  2. An autosomal recessive disorder of the exocrine glands marked by increased mucus and sodium chloride production and decreased pancreatic enzyme production.
  3. An autosomal recessive disorder that affects the respiratory, cardiac, and digestive systems.
  4. An autosomal recessive disorder that is marked by the increased mucus destruction and decreased pancreatic enzyme production.

 

ANS: 2

  Feedback
1. Cystic fibrosis is an autosomal recessive disorder of exocrine glands and is not seen on chromosome 17.
2. Cystic fibrosis is an autosomal recessive disorder of exocrine glands marked by increased mucus and sodium chloride production and decreased pancreatic enzyme production.
3. Cystic fibrosis is an autosomal recessive disorder that impacts the respiratory and GI tract, not the heart.
4. Cystic fibrosis is an autosomal recessive disorder of the exocrine glands marked by increased mucus and sodium chloride production and decreased pancreatic enzyme production.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Which statement is most accurate regarding chest physiotherapy (CP)?
  2. CP includes postural drainage, chest percussion, vibration, and daily chest x-rays.
  3. CP is used to mechanically loosen secretions to prevent or manage atelectasis and gastritis.
  4. CP should only be performed in the absence of respiratory distress.
  5. CP is contraindicated when chest rib fractures, lung contusions, or hemothorax are present.

 

ANS: 4

  Feedback
1. CP does not require daily X-rays.
2. CP is not used for gastritis.
3. CP should only be done with patients with an increase in respiratory secretions.
4.  Chest physiotherapy is contraindicated when rib fractures, lung contusions, or hemothorax are present because further damage can occur.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 6 year old who exhibits a moist, productive cough has a history of bronchitis several times every year and “eating everything in sight.” She appears thin for her age and has a sweat chloride test that is 67 mEQ/L. Her mother states, “I just want to get this eating disorder treated so my baby can have a normal life.” What is the nurse’s best response?
  2. “We will consult the dietician for a behavior management and eating plan, focusing on appropriate portion size.”
  3. “We will need to do another sweat chloride test next week. Have your child take supplemental water-soluble vitamins, such as A, D, K and iron.”
  4. “You should incorporate tofu and mayonnaise in your meal preparation to promote feeling full for a longer period of time.”
  5. “Cystic fibrosis can cause an increase in appetite because of the lack of nutrients and calories absorbed. This affects children across the life span.”

 

ANS: 4

  Feedback
1. Food choices that contain the needed vitamins and minerals should be discussed.
2. The child already has the diagnosis and another test will not indicate which vitamins to give.
3. This diet will not easily be digested by a person with CF. The menu should be reconsidered.
4. Increased appetite is a physiologic response to decreased fat-soluble nutrients and calories absorbed in the CF digestive track.  This requires fat-soluble (A,D, E, K) vitamins and pancreatic enzyme supplements.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The nurse is doing discharge teaching with the parents of a child with new diagnosis of CF. What is the most important concept for parents of CF patients to remember?
  2. Hospitalizations can be avoided with consistent chest physiotherapy.
  3. There are multiple support groups in the community available to help them cope when the symptoms increase as the child grows older.
  4. It affects multiple body systems over a lifetime, which requires vigilant respiratory care and individualized dietary modifications.
  5. All symptoms of cystic fibrosis can be managed by diet modifications and increasing the fluids and salt intake of the child.

 

ANS: 3

  Feedback
1. Multiple adaptations to the lifestyle will be needed to maintain a healthy body and avoid hospitalizations.
2. Support groups and summer camps should be implemented right away to learn how to adapt to the illness emotionally.
3. It affects multiple body systems over a lifetime, which requires vigilant respiratory care and individualized dietary modifications.
4. Some individuals will be more ill than others and need different modifications to their diet.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. What is the major contributing factor for the development of BPD?
  2. Immature lungs have a decreased number of alveoli for gas exchange
  3. Premature birth with decreased number of functional alveoli, leading to lung injury
  4. Chronic respiratory infections, leading to pulmonary hypertension and lung scarring
  5. Ventilator assistance with high oxygen flow rate at birth, causing inflammation and scarring in lungs

 

ANS: 4

  Feedback
1. BPD occurs because of the increased resistance and amount of damaged alveoli, decreasing the amount of oxygen exchange.
2.  Scarring occurs on the alveoli that are present. The preemie baby has the same amount of alveoli, but less surface area to ventilate.
3. Neonates do not commonly have respiratory infections to cause an increased risk for BPD.
4. Ventilator assistance with high oxygen flow rate at birth, causing inflammation and scarring in lungs

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. If a nurse suspects that a 2-month-old infant’s death was related to SIDS, what statement made by the mother reflects an accurate understanding of SIDS?
  2. “I knew that I should not have given our baby the antibiotics for the ear infection.”
  3. “Being a twin with low birth weight, he didn’t have a chance.”
  4. “I should not have fed him that eight-ounce bottle before laying him down.”
  5. “I am having a hard time not knowing what happened. I had just checked on him 20 minutes earlier in the crib, and he was sleeping on his back.”

 

ANS: 4

  Feedback
1. SIDS is a diagnosis of exclusion. Antibiotics are not known to cause SIDS.
2. A lower birth weight child is at more risk, but is not the only reason SIDS can occur.
3. The amount of feeding does not influence the occurrence of SIDS.
4. SIDS is a diagnosis of exclusion. It is difficult to know what exactly causes the death in SIDS cases.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An infant is tachypneic, retracting, and tachycardic with a temp of 39.0 C and a pulse oximetry of 92 percent. You place the infant on 1L nasal cannula oxygen and raise the head of the bed. What intervention would the nurse expect the physician to order next?
  2. MRI
  3. CT
  4. Bronchoscopy
  5. Chest x-ray

 

ANS: 4

  Feedback
1. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.
2. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.
3. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.
4. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.

KEY: Content Area: Respiratory Therapy | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The parents of a 3 year old from India state that the child has been losing weight and coughing for a year. Additionally, the child’s grandmother was diagnosed with TB. Which of the following is the most accurate statement regarding this situation?
  2. Tubercules are more prevalent in children than adults, and all family members should be tested for TB.
  3. Prevalence is high in developing countries, and only 20 percent of complete treatment because the length, intensity, and cost of treatment.
  4. A blood culture is the definitive diagnosis for TB after a negative skin test.
  5. Diagnosing TB in children is difficult because it varies with the changes in the seasons, and the symptoms can be vague.

 

ANS: 2

  Feedback
1. TB is more prevalent in adults than children.
2. Prevalence is high in developing countries, and only 20 percent of complete treatment because the length, intensity, and cost of treatment.
3. The Mantoux test gives an indication as to whether TB is present in the person’s body.
4. TB presents the same no matter the season in both children and adults.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The most accurate physiologic reason for respiratory distress in respiratory distress syndrome (RDS) is:
  2. Altered surface tension causes fluid and protein leak, preventing atelectasis and ground glass appearance on CXR.
  3. Infants with RDS are premature and incidence of RDS increases with increased gestational age.
  4. Infants with RDS have a decreased number of alveoli, increased surface tension, and decreased AP diameter, limiting lung development.
  5. Infants with RDS have altered surface tension, which produces hyaline membrane, atelectasis, and hypoventilation.

 

ANS: 4

  Feedback
1. The hypoventilation occurring in RDS causes an increased risk.
2. RDS can occur in any gestational age neonate.
3. The neonates have damage to the alveoli, not a decreased number.
4. Infants with RDS have altered surface tension, which produces, hyaline membrane, atelectasis and hypoventilation.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiology Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

Multiple Response

 

 

 

  1. Signs that a child is exhibiting respiratory distress include: (Select all that apply.)
  2. Nasal flaring.
  3. Synchronized rise and fall of the abdomen and the chest.
  4. A capillary refill of less than three seconds.
  5. Grunting.
  6. Intercostal retractions.

 

ANS: 1, 4, 5

  Feedback
1. Nasal flaring indicates that the child is struggling with breathing.
2. Synchronized rise and fall is a normal breathing pattern of a child.
3. A capillary refill of less than 3 seconds is normal for a child.
4. Grunting indicates that the child has to exhale harder than normal, thus indicating respiratory distress.
5. Intercostal retractions indicate that the child needs to use accessory muscles, creating respiratory distress.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response

 

 

 

  1. The father of a 13-year-old boy with sinusitis calls the triage nurse at the pediatric clinic to ask what he can do to rest. The nurse should advise the father to: (Select all that apply.)
  2. Place a cold compress on the infected sinus areas.
  3. Have the child blow his nose with one nostril closed off at a time.
  4. Use a warm mist humidifier in his bedroom.
  5. Use saline drops to help clear the nasal passage.
  6. Use a bulb syringe to remove secretions.

ANS: 2, 4, 5

  Feedback
1. Cold compresses will not encourage drainage.
2. Attempting to blow a nose with one nostril closed at a time helps provide pressure to remove the secretions.
3. A cool mist humidifier should be used to help reduce the chance of steam burns.
4. Saline drops can keep the airways moist and help remove secretions.
5. The child is too old for bulb syringe suction. Blowing the nose is just as effective.

KEY: Content Area: HEENT | Integrated Processes: Teaching/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter11 | Type: Multiple Response

 

 

 

  1. A nurse is giving discharge instructions to parents taking a newborn home with apneic episodes. The newborn has an apnea monitor for home. The instructions should include: (Select all that apply.)
  2. How to clean the monitor pieces.
  3. Allowing the monitor to be off when the parents are sitting with the newborn in an awake state.
  4. Never take the monitor off.
  5. Take the monitor off when bathing the baby.
  6. Reset the alarm limits if the monitor is ringing frequently.

 

ANS: 1, 2, 4

  Feedback
1. Keeping the pieces clean will aid in decreasing the chances for infection and help maintain a working monitor.
2. The newborn can be off the monitor while awake, and being supervised helps decrease skin breakdown.
3. The monitor should be taken off for periods while the newborn is awake and supervised.
4. Since the monitor is electric, it should not become wet at any time.
5. The alarm limits are prescribed by a provider and should not be reset.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response

 

 

 

  1. Parents are attending a pre-baby class and receiving information on SIDS. Identify important information the nurse should provide during the course. Select all that apply.
  2. A firm mattress
  3. A bendy bumper around the entire bed
  4. A pillow
  5. Tight-fitting sheets
  6. A well-ventilated room

 

ANS: 1, 4, 5

  Feedback
1. A firm mattress keeps the baby from sinking into the bedding, thus preventing suffocation.
2. Bendy bumpers can create pockets for the infant’s face to become stuck, thus creating a suffocation risk.
3. A pillow is too bulky and can cause an infant to become stuck, thus creating a suffocation risk.
4. Tight-fitting sheets decrease the chance for suffocation because there is little room for the infant’s head to get stuck.
  A well-ventilated room creates air movement and a good exchange of oxygen and carbon dioxide.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response

 

 

 

Matching

 

 

 

  1. A nurse is discussing the process in which tuberculosis can infect a child. Place the following in the correct order.

__ Sputum specimen is obtained

__ Tubercles are dormant

__ Bacillus triggers the immune response

__ Bacilli spread to the lymphatic system

__ Macrophages form tubercles around bacilli

ANS: 5, 4, 1, 3, 2

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Matching

 

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